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General NPI Number Information
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NPI Number | 1790409613
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Entity Type | Individual
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Provider Name | MRS. TANYA DEPETRIS
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Gender | Female
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Dates
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Enumeration Date | 10/04/2022
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Last Update Date | 10/04/2022
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Provider Practice Location Address
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Address Line | 6614 SHALLOWFORD RD STE 250
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City | LEWISVILLE
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State | NC
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Zip | 27023-9305
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Country | US
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Telephone | 336-945-0137
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Fax |
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Provider Business Mailing Address
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Address Line | 903 DODSON MILL RD
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City | PILOT MOUNTAIN
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State | NC
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Zip | 27041-9372
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Country | US
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Telephone | 336-755-8470
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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