Provider Demographics
NPI:1336536838
Name:BRACKEN, ANGELA MICHELLE (BA)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MICHELLE
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:MICHELLE
Other - Last Name:HICKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1430 OLIVE ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-2303
Mailing Address - Country:US
Mailing Address - Phone:314-452-4414
Mailing Address - Fax:314-206-3708
Practice Address - Street 1:1430 OLIVE ST
Practice Address - Street 2:SUITE 500
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2303
Practice Address - Country:US
Practice Address - Phone:314-452-4414
Practice Address - Fax:314-206-3708
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator