Provider Demographics
NPI:1700667508
Name:MISHOU, ANGELA (COTA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MISHOU
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 OAK ST
Mailing Address - Street 2:
Mailing Address - City:OLD TOWN
Mailing Address - State:ME
Mailing Address - Zip Code:04468-1639
Mailing Address - Country:US
Mailing Address - Phone:207-299-6946
Mailing Address - Fax:
Practice Address - Street 1:42 BUCKSPORT RD
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-2230
Practice Address - Country:US
Practice Address - Phone:207-667-9036
Practice Address - Fax:207-667-7197
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA1162224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant