Provider Demographics
NPI:1093010241
Name:CONWAY, ANGELA MICHELLE (PSYD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MICHELLE
Last Name:CONWAY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 SOUTH MAIN STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540
Mailing Address - Country:US
Mailing Address - Phone:630-292-0029
Mailing Address - Fax:
Practice Address - Street 1:50 SOUTH MAIN STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-1114
Practice Address - Country:US
Practice Address - Phone:630-292-0029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-19
Last Update Date:2016-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008483103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF300213038Medicare PIN