Provider Demographics
NPI:1134740947
Name:WILLARD, ANGELA MARIE (MA CCC/SLP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:WILLARD
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MILLERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44654-1464
Mailing Address - Country:US
Mailing Address - Phone:330-936-3091
Mailing Address - Fax:
Practice Address - Street 1:1261 WOOSTER RD
Practice Address - Street 2:
Practice Address - City:MILLERSBURG
Practice Address - State:OH
Practice Address - Zip Code:44654-1568
Practice Address - Country:US
Practice Address - Phone:330-674-9066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.08284235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist