Provider Demographics
NPI:1356467799
Name:SALLAS, ANGELIQUE A (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANGELIQUE
Middle Name:A
Last Name:SALLAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N WABASH AVE
Mailing Address - Street 2:SUITE 2005
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1903
Mailing Address - Country:US
Mailing Address - Phone:312-266-0489
Mailing Address - Fax:312-345-8149
Practice Address - Street 1:111 N WABASH AVE
Practice Address - Street 2:SUITE 2005
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1903
Practice Address - Country:US
Practice Address - Phone:312-266-0489
Practice Address - Fax:312-345-8149
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-002120103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical