Provider Demographics
NPI:1790037018
Name:NORTHCUTT, ANGELA LYN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LYN
Last Name:NORTHCUTT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:LYN
Other - Last Name:MONTEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2425 E SOUTHLAKE BLVD
Mailing Address - Street 2:#100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6674
Mailing Address - Country:US
Mailing Address - Phone:817-442-0222
Mailing Address - Fax:817-442-0223
Practice Address - Street 1:2425 E SOUTHLAKE BLVD
Practice Address - Street 2:#100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6674
Practice Address - Country:US
Practice Address - Phone:817-442-0222
Practice Address - Fax:817-442-0223
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104403235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist