Basic Information
| Provider Information | |||||||||
| NPI: | 1033310172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANGEL | ||||||||
| FirstName: | ANASTACIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | QMHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4533 ARABIAN CT SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973016024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033613722 | ||||||||
| FaxNumber: | 5035854990 | ||||||||
| Practice Location | |||||||||
| Address1: | 2421 LANCASTER DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035612722 | ||||||||
| FaxNumber: | 5035854990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.