Basic Information
| Provider Information | |||||||||
| NPI: | 1265823066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLEIN | ||||||||
| FirstName: | ANGELENA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEONE | ||||||||
| OtherFirstName: | ANGELENA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1939 S DIVISION AVE. | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162473815 | ||||||||
| FaxNumber: | 6162450450 | ||||||||
| Practice Location | |||||||||
| Address1: | 1939 S DIVISION AVE. | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162473815 | ||||||||
| FaxNumber: | 6162450450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2015 | ||||||||
| LastUpdateDate: | 02/28/2018 | ||||||||
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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 | 1041C0700X | 6801098273 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.