Provider Demographics
NPI:1740753318
Name:URIBE, ANGEL MAUREEN (LADC)
Entity Type:Individual
Prefix:MS
First Name:ANGEL
Middle Name:MAUREEN
Last Name:URIBE
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WARREN ST STE 307
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-3788
Mailing Address - Country:US
Mailing Address - Phone:507-514-8057
Mailing Address - Fax:507-519-2331
Practice Address - Street 1:100 WARREN ST STE 307
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3788
Practice Address - Country:US
Practice Address - Phone:507-514-8057
Practice Address - Fax:507-519-2331
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302961101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)