Provider Demographics
NPI:1083234959
Name:HORNER, ANGELA D (LADC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:D
Last Name:HORNER
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 8TH ST SE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-2819
Mailing Address - Country:US
Mailing Address - Phone:218-847-0696
Mailing Address - Fax:218-847-4198
Practice Address - Street 1:1301 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-4407
Practice Address - Country:US
Practice Address - Phone:218-847-4491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301943101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN301943OtherLADC LICENSE