Provider Demographics
NPI:1790400034
Name:YANG, ANGELICA
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:YANG
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 1:1706 S WALTON BLVD UNIT 835
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-2646
Mailing Address - Country:US
Mailing Address - Phone:479-301-9132
Mailing Address - Fax:
Practice Address - Street 1:1732 SE MOBERLY LN
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-9239
Practice Address - Country:US
Practice Address - Phone:479-301-9132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP2209022OtherLPC LICENSE