Provider Demographics
NPI:1174691232
Name:TANGELLA, VIJAYA VENKATA (MA)
Entity type:Individual
Prefix:MRS
First Name:VIJAYA
Middle Name:VENKATA
Last Name:TANGELLA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 CHAPPELL DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-3215
Mailing Address - Country:US
Mailing Address - Phone:919-832-3909
Mailing Address - Fax:919-832-3035
Practice Address - Street 1:739 CHAPPELL DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-3215
Practice Address - Country:US
Practice Address - Phone:919-832-3909
Practice Address - Fax:919-832-3035
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1439103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14195OtherBCBS OF NC
NC6107363Medicaid