Healthcare Provider Details

I. General information

NPI: 1174681209
Provider Name (Legal Business Name): NANCY M DEVEREUX PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NANCY FORREST

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 WEST 14TH STREET 6TH FLOOR
WILMINGTON DE
19801
US

IV. Provider business mailing address

200 HYGEIA DRIVE PHYSICIAN CONTRACTING - SUITE 2300
NEWARK DE
19713
US

V. Phone/Fax

Practice location:
  • Phone: 302-428-6756
  • Fax: 302-428-6750
Mailing address:
  • Phone: 302-623-7010
  • Fax: 302-623-0394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071005310
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071005310
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberB1-0001049
License Number StateDE
# 4
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberB1-0001049
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: