Provider Demographics
NPI:1942391180
Name:KOESTLER, ANGELA J (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:J
Last Name:KOESTLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16525 HIGHWAY 465
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-7941
Mailing Address - Country:US
Mailing Address - Phone:601-634-0118
Mailing Address - Fax:601-630-0302
Practice Address - Street 1:1121 GROVE ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-2913
Practice Address - Country:US
Practice Address - Phone:601-634-0118
Practice Address - Fax:601-630-0302
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS361103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS640665522OtherTAX ID NUMBER