Provider Demographics
NPI:1023171998
Name:ANGELOS, DWYLA J (MA, LMHC)
Entity type:Individual
Prefix:MS
First Name:DWYLA
Middle Name:J
Last Name:ANGELOS
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 BLUE HILL AVE.
Mailing Address - Street 2:PRIORITY PROFESSIONAL CARE SUITE 302
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126
Mailing Address - Country:US
Mailing Address - Phone:857-598-4774
Mailing Address - Fax:857-598-4816
Practice Address - Street 1:1613 BLUE HILL AVE.
Practice Address - Street 2:PRIORITY PROFESSIONAL CARE SUITE 302
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126
Practice Address - Country:US
Practice Address - Phone:857-598-4774
Practice Address - Fax:857-598-4816
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA603101YM0800X
MALMHC 603101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional