Provider Demographics
NPI:1659006294
Name:MARCOS, ANGELICA (PTA)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:MARCOS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5641 W HOLLY HILLS RD
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:IN
Mailing Address - Zip Code:47243-9224
Mailing Address - Country:US
Mailing Address - Phone:812-493-3426
Mailing Address - Fax:
Practice Address - Street 1:1023 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VEVAY
Practice Address - State:IN
Practice Address - Zip Code:47043-9192
Practice Address - Country:US
Practice Address - Phone:812-427-2803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005908A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant