Provider Demographics
NPI:1093278269
Name:CHAN, ANGIE CEELOK
Entity Type:Individual
Prefix:MS
First Name:ANGIE
Middle Name:CEELOK
Last Name:CHAN
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 1:307 INTERNATIONAL CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21030-1387
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:388 PERKINS MADDEN RD
Practice Address - Street 2:
Practice Address - City:HINDMAN
Practice Address - State:KY
Practice Address - Zip Code:41822-9003
Practice Address - Country:US
Practice Address - Phone:606-785-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY246561235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14036706OtherAMERICAN SPEECH-HEARING-LANGUAGE ASSOCIATION
OHSP.11058OtherSTATE LICENSE
KY246561OtherSTATE LICENSE