Provider Demographics
NPI:1619367919
Name:FOURNIER, ANGELA KROM (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:KROM
Last Name:FOURNIER
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 BIRCHMONT DR. NW
Mailing Address - Street 2:DEPT. OF PSYCHOLOGY #23
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601
Mailing Address - Country:US
Mailing Address - Phone:218-755-2530
Mailing Address - Fax:
Practice Address - Street 1:16150 GOLDEN EAGLE COURT NW
Practice Address - Street 2:EAGLE VISTA EQUINE CENTER INC.
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601
Practice Address - Country:US
Practice Address - Phone:218-760-0656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5076103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical