Basic Information
| Provider Information | |||||||||
| NPI: | 1093747149 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANGELES | ||||||||
| FirstName: | BERNADETTE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANGELES | ||||||||
| OtherFirstName: | LOURDES BERNADETTE | ||||||||
| OtherMiddleName: | S. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 42450 W 12 MILE RD | ||||||||
| Address2: | 315 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483773013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485134100 | ||||||||
| FaxNumber: | 2485134105 | ||||||||
| Practice Location | |||||||||
| Address1: | 42450 W 12 MILE RD | ||||||||
| Address2: | 315 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483773013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485134100 | ||||||||
| FaxNumber: | 2485134105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 03/30/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 4301074466 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.