Basic Information
Provider Information | |||||||||
NPI: | 1508279498 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HITTI | ||||||||
FirstName: | ANGEL | ||||||||
MiddleName: | MORNINGSTAR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | REEVE | ||||||||
OtherFirstName: | ANGEL | ||||||||
OtherMiddleName: | MORNINGSTAR | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1328 | ||||||||
Address2: |   | ||||||||
City: | DURANGO | ||||||||
State: | CO | ||||||||
PostalCode: | 813021328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9703352238 | ||||||||
FaxNumber: | 9705659005 | ||||||||
Practice Location | |||||||||
Address1: | 281 SAWYER DR STE 100 | ||||||||
Address2: |   | ||||||||
City: | DURANGO | ||||||||
State: | CO | ||||||||
PostalCode: | 813033409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702592162 | ||||||||
FaxNumber: | 9702475255 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2014 | ||||||||
LastUpdateDate: | 11/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 1041C0700X | CSW.09927309 | CO | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 88-6000022 | 05 | NV |   | MEDICAID |