Provider Demographics
NPI:1114474772
Name:ANGELO, KEYSE
Entity Type:Individual
Prefix:
First Name:KEYSE
Middle Name:
Last Name:ANGELO
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:KEYSE ANGELO
Mailing Address - Street 2:26 COLBERG AVE, #3
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131
Mailing Address - Country:US
Mailing Address - Phone:617-642-8393
Mailing Address - Fax:
Practice Address - Street 1:26 COLBERG AVE APT 3
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-2858
Practice Address - Country:US
Practice Address - Phone:617-642-8393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1224521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical