Provider Demographics
NPI:1790158509
Name:STAR, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:STAR
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 1:2419 NEBRASKA AVE E
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55119-7174
Mailing Address - Country:US
Mailing Address - Phone:651-308-1133
Mailing Address - Fax:651-772-3183
Practice Address - Street 1:621 W LAKE ST
Practice Address - Street 2:LYNLAKE BLDG #350
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2949
Practice Address - Country:US
Practice Address - Phone:651-308-1133
Practice Address - Fax:612-486-8800
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304238101YA0400X
MN83431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)