Provider Demographics
NPI:1770676231
Name:NULL, ANGELA D (MS)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:D
Last Name:NULL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 6TH AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1265
Mailing Address - Country:US
Mailing Address - Phone:304-768-6170
Mailing Address - Fax:304-768-2099
Practice Address - Street 1:312 6TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1265
Practice Address - Country:US
Practice Address - Phone:304-768-6170
Practice Address - Fax:304-768-2099
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV754103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV550764076OtherACORDIA NATIONAL
WV001710841OtherBLUE CROSS BLUE SHIELD