Provider Demographics
NPI:1114532108
Name:BAVONE, ANGELA MARIE (CMT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:BAVONE
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4470 W SUNSET BLVD # 91723
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6302
Mailing Address - Country:US
Mailing Address - Phone:310-425-4913
Mailing Address - Fax:
Practice Address - Street 1:422 WARREN LN # 14B
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90302-3116
Practice Address - Country:US
Practice Address - Phone:310-425-4913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63585225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist