Provider Demographics
NPI:1760675896
Name:ANGEL, MARTHA H (PSYD, LCPC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:H
Last Name:ANGEL
Suffix:
Gender:F
Credentials:PSYD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 LORRAINE CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2547
Mailing Address - Country:US
Mailing Address - Phone:847-630-7818
Mailing Address - Fax:
Practice Address - Street 1:292 LORRAINE CIR
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2547
Practice Address - Country:US
Practice Address - Phone:847-630-7818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.005122103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical