Provider Demographics
NPI:1578773461
Name:ANGELINI, DEIDRE MARIE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:DEIDRE
Middle Name:MARIE
Last Name:ANGELINI
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MISS
Other - First Name:DEIDRE
Other - Middle Name:MARIE
Other - Last Name:KOTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:158 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19056-2730
Mailing Address - Country:US
Mailing Address - Phone:215-547-3809
Mailing Address - Fax:
Practice Address - Street 1:1 N BELFIELD AVE
Practice Address - Street 2:SUNNY DAYS
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4904
Practice Address - Country:US
Practice Address - Phone:610-449-1600
Practice Address - Fax:610-449-2655
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC006947L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001936830-0003Medicaid