Basic Information
| Provider Information | |||||||||
| NPI: | 1639347636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDWINE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PH.D., LPC-MHSP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 640 | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371110640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315071212 | ||||||||
| FaxNumber: | 9315071217 | ||||||||
| Practice Location | |||||||||
| Address1: | 1511 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | TULLAHOMA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373882343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314556213 | ||||||||
| FaxNumber: | 9314556225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2008 | ||||||||
| LastUpdateDate: | 04/19/2012 | ||||||||
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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 | 103TA0700X | N | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | 101YP2500X | 2784 | TN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 2784 | 01 | TN | LICENSE | OTHER |