Provider Demographics
NPI:1083488720
Name:MYERS, ANGELA RENEE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:RENEE
Last Name:MYERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 SHADY LANE DR
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-3815
Mailing Address - Country:US
Mailing Address - Phone:803-760-9446
Mailing Address - Fax:
Practice Address - Street 1:240 SHADY LANE DR
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-3815
Practice Address - Country:US
Practice Address - Phone:803-760-9446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty