Provider Demographics
NPI:1558841569
Name:BACAK, ANGELA (PSYS)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BACAK
Suffix:
Gender:F
Credentials:PSYS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6986 POLPIS RD
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-7170
Mailing Address - Country:US
Mailing Address - Phone:330-503-6241
Mailing Address - Fax:
Practice Address - Street 1:145 N QUENTIN RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-4623
Practice Address - Country:US
Practice Address - Phone:740-349-6084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-19
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3282914103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool