Provider Demographics
NPI:1083214837
Name:IMPSON, ANGELA (LOTR)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:IMPSON
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3468 BEVERLY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2022
Mailing Address - Country:US
Mailing Address - Phone:318-517-4948
Mailing Address - Fax:
Practice Address - Street 1:8039 LINE AVE STE 1B
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-5145
Practice Address - Country:US
Practice Address - Phone:318-861-1965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA303345225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist