Provider Demographics
NPI:1750822615
Name:MCINNIS, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MCINNIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 PETE MARTIN RD
Mailing Address - Street 2:
Mailing Address - City:ANACOCO
Mailing Address - State:LA
Mailing Address - Zip Code:71403-3346
Mailing Address - Country:US
Mailing Address - Phone:903-399-6679
Mailing Address - Fax:
Practice Address - Street 1:302 PETE MARTIN RD
Practice Address - Street 2:
Practice Address - City:ANACOCO
Practice Address - State:LA
Practice Address - Zip Code:71403
Practice Address - Country:US
Practice Address - Phone:903-399-6679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-12
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health