Provider Demographics
NPI:1821738659
Name:VICKERS, ANGELINA
Entity Type:Individual
Prefix:
First Name:ANGELINA
Middle Name:
Last Name:VICKERS
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 1:500 BILL FRANCE BLVD UNIT 11465
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-7102
Mailing Address - Country:US
Mailing Address - Phone:407-900-7905
Mailing Address - Fax:
Practice Address - Street 1:121 W PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3429
Practice Address - Country:US
Practice Address - Phone:386-258-1618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2023-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH19970101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health