Basic Information
Provider Information | |||||||||
NPI: | 1093855934 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAWSON | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | KATHLEEN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | COASTAL CHILD DR ANGELA DAWSON | ||||||||
Address2: | 1331 OCEAN BLVD SUITE 103 | ||||||||
City: | ST. SIMONS ISLAND | ||||||||
State: | GA | ||||||||
PostalCode: | 31522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7065093000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | COASTAL CHILD | ||||||||
Address2: | 1331 OCEAN BLVD SUITE 103 | ||||||||
City: | ST. SIMONS ISLAND | ||||||||
State: | GA | ||||||||
PostalCode: | 31522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7065093500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/08/2007 | ||||||||
LastUpdateDate: | 05/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 040895 | GA | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 000751638F | 05 | GA |   | MEDICAID |