Basic Information
| Provider Information | |||||||||
| NPI: | 1174681209 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVEREUX | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FORREST | ||||||||
| OtherFirstName: | NANCY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 HYGEIA DRIVE | ||||||||
| Address2: | PHYSICIAN CONTRACTING - SUITE 2300 | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026237010 | ||||||||
| FaxNumber: | 3026230394 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 WEST 14TH STREET | ||||||||
| Address2: | 6TH FLOOR | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3024286756 | ||||||||
| FaxNumber: | 3024286750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 03/24/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 071005310 | IL | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | 071005310 | IL | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | B1-0001049 | DE | N | Behavioral Health & Social Service Providers | Psychologist | 103G00000X | B1-0001049 | DE | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 363236791 | 01 | IL | TAX ID | OTHER |