Provider Demographics
NPI:1083910541
Name:DAWSON, ANGELA ROSHELLE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:ROSHELLE
Last Name:DAWSON
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 1:17 LANE AVE
Mailing Address - Street 2:APT 14
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-1928
Mailing Address - Country:US
Mailing Address - Phone:864-631-9849
Mailing Address - Fax:
Practice Address - Street 1:1178 WOODRUFF RD
Practice Address - Street 2:SUITE 5
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4130
Practice Address - Country:US
Practice Address - Phone:864-631-9849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-01
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6696225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist