Provider Demographics
NPI:1972702660
Name:DEBASTOS, ANGELA K (PHD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:K
Last Name:DEBASTOS
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 1:410 W UNIVERSITY DR
Mailing Address - Street 2:#205
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1938
Mailing Address - Country:US
Mailing Address - Phone:248-651-9670
Mailing Address - Fax:248-651-9675
Practice Address - Street 1:410 W UNIVERSITY DR
Practice Address - Street 2:#205
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1938
Practice Address - Country:US
Practice Address - Phone:248-651-9670
Practice Address - Fax:248-651-9675
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014168103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist