Provider Demographics
NPI:1851759245
Name:ANDERSON, ANGELA ANTONIA (PSS)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:ANTONIA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 E MAIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7140
Mailing Address - Country:US
Mailing Address - Phone:541-779-1282
Mailing Address - Fax:541-608-2888
Practice Address - Street 1:1003 E MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-779-1282
Practice Address - Fax:541-608-2888
Is Sole Proprietor?:No
Enumeration Date:2016-02-01
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000003687171M00000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator