Provider Demographics
NPI:1851963441
Name:SUTHERLAND, ANGIE NICOLE (LMT, CMMP)
Entity Type:Individual
Prefix:MRS
First Name:ANGIE
Middle Name:NICOLE
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:LMT, CMMP
Other - Prefix:MRS
Other - First Name:ANGIE
Other - Middle Name:NICOLE
Other - Last Name:REMMERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT, CMMP,CMLDP
Mailing Address - Street 1:1806 N. MARKET STREET
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822
Mailing Address - Country:US
Mailing Address - Phone:217-650-9362
Mailing Address - Fax:
Practice Address - Street 1:1806 N. MARKET STREET
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822
Practice Address - Country:US
Practice Address - Phone:217-650-9362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL227.020137225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist