Provider Demographics
NPI:1790557635
Name:MILLS, ANGELINA JOLIE (SUDRC)
Entity type:Individual
Prefix:
First Name:ANGELINA
Middle Name:JOLIE
Last Name:MILLS
Suffix:
Gender:F
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2257 HURLEY WAY APT 13
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2324
Mailing Address - Country:US
Mailing Address - Phone:267-583-5335
Mailing Address - Fax:
Practice Address - Street 1:9340 E STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1563
Practice Address - Country:US
Practice Address - Phone:267-583-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14549101YA0400X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)