Provider Demographics
NPI:1346418902
Name:ULLRICH, ANGI LYN (MS)
Entity Type:Individual
Prefix:MRS
First Name:ANGI
Middle Name:LYN
Last Name:ULLRICH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:ANGI
Other - Middle Name:LYN
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1942 E. CANTRELL ST
Mailing Address - Street 2:
Mailing Address - City:DECATOR
Mailing Address - State:IL
Mailing Address - Zip Code:62521
Mailing Address - Country:US
Mailing Address - Phone:217-423-6961
Mailing Address - Fax:
Practice Address - Street 1:1942 E. CANTRELL ST
Practice Address - Street 2:
Practice Address - City:DECATOR
Practice Address - State:IL
Practice Address - Zip Code:62521
Practice Address - Country:US
Practice Address - Phone:217-423-6961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-18
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006700101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional