Provider Demographics
NPI:1083131411
Name:ENTZ, ANGELA JOY (COTA)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:JOY
Last Name:ENTZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 N ROCK RD APT 1202
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-1184
Mailing Address - Country:US
Mailing Address - Phone:316-208-9415
Mailing Address - Fax:
Practice Address - Street 1:622 N EDGEMOOR ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3602
Practice Address - Country:US
Practice Address - Phone:316-686-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01147224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1891742573Medicaid