Provider Demographics
NPI:1861627168
Name:ANGELOS, GAYLENE
Entity Type:Individual
Prefix:
First Name:GAYLENE
Middle Name:
Last Name:ANGELOS
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 1:102 NE 12TH ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-8184
Mailing Address - Country:US
Mailing Address - Phone:360-687-5826
Mailing Address - Fax:360-687-8526
Practice Address - Street 1:410 E 20TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3316
Practice Address - Country:US
Practice Address - Phone:360-687-5826
Practice Address - Fax:360-687-8526
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-16
Last Update Date:2009-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00007174101YM0800X
ORC1729101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health