Provider Demographics
NPI:1982956744
Name:CARLOS, ANGELA MARY (MA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARY
Last Name:CARLOS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 BUFFALO AVE APT 902
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14303-1235
Mailing Address - Country:US
Mailing Address - Phone:716-400-4206
Mailing Address - Fax:
Practice Address - Street 1:400 SOLDIER CREEK DR
Practice Address - Street 2:
Practice Address - City:ROSEBUD
Practice Address - State:SD
Practice Address - Zip Code:57570-8502
Practice Address - Country:US
Practice Address - Phone:716-400-4206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2020-03-02
Deactivation Date:2018-05-15
Deactivation Code:
Reactivation Date:2020-02-26
Provider Licenses
StateLicense IDTaxonomies
PAPC008323101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional