Provider Demographics
NPI:1508279498
Name:RADDATZ, ANGEL MORNINGSTAR
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:MORNINGSTAR
Last Name:RADDATZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGEL
Other - Middle Name:MORNINGSTAR
Other - Last Name:HITTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-1328
Mailing Address - Country:US
Mailing Address - Phone:970-335-2238
Mailing Address - Fax:970-565-9005
Practice Address - Street 1:281 SAWYER DR STE 100
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-3409
Practice Address - Country:US
Practice Address - Phone:970-259-2162
Practice Address - Fax:970-247-5255
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
COCSW.099273091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV88-6000022Medicaid