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General NPI Number Information
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NPI Number | 1831205400
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Entity Type | Individual
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Provider Name | AMANDA KATHERINE VAN EMBURGH PSYD
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Gender | Female
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Dates
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Enumeration Date | 08/23/2006
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Last Update Date | 10/02/2008
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Provider Practice Location Address
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Address Line | 725 HIGHLAND AVE
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City | WINSTON SALEM
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State | NC
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Zip | 27101-4206
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Country | US
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Telephone | 336-607-8523
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Fax |
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Provider Business Mailing Address
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Address Line | 720 OLD GASTON PL
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City | WINSTON SALEM
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State | NC
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Zip | 27103-3878
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Country | US
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Telephone | 703-864-4444
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 3620
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License Number State | NC
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