Provider Demographics
NPI:1760521694
Name:ISAAC, ANGIE JOHNSON (EDS)
Entity Type:Individual
Prefix:MISS
First Name:ANGIE
Middle Name:JOHNSON
Last Name:ISAAC
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1869 W MANOR ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5108
Mailing Address - Country:US
Mailing Address - Phone:480-786-0611
Mailing Address - Fax:
Practice Address - Street 1:2013 N 36TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-3026
Practice Address - Country:US
Practice Address - Phone:602-381-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ076869OtherAHCCCS PROVIDER NUMBER