Provider Demographics
NPI:1952707853
Name:PEREGUD-AKSIMENTYEVA, ANGELA (LCPC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:PEREGUD-AKSIMENTYEVA
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:PEREGUD-AKSIMENTYEVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCPC
Mailing Address - Street 1:101 E LIBERTY LN
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-1442
Mailing Address - Country:US
Mailing Address - Phone:217-431-8825
Mailing Address - Fax:217-431-8827
Practice Address - Street 1:101 E LIBERTY LN
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-1442
Practice Address - Country:US
Practice Address - Phone:217-431-8825
Practice Address - Fax:217-431-8827
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009193101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3360Medicaid