Provider Demographics
NPI:1396040390
Name:FAMOUS, ANGELA MARIE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:FAMOUS
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:PO BOX 421141
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92142-1141
Mailing Address - Country:US
Mailing Address - Phone:619-276-8112
Mailing Address - Fax:619-276-8230
Practice Address - Street 1:1401 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5710
Practice Address - Country:US
Practice Address - Phone:619-276-8112
Practice Address - Fax:619-276-8230
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70303106H00000X
CA99943106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist