Provider Demographics
NPI:1023475225
Name:MICHAEL, ANGELA (IECE)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:IECE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HORSE CAVE
Mailing Address - State:KY
Mailing Address - Zip Code:42749-1205
Mailing Address - Country:US
Mailing Address - Phone:270-670-5357
Mailing Address - Fax:844-688-4227
Practice Address - Street 1:308 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HORSE CAVE
Practice Address - State:KY
Practice Address - Zip Code:42749
Practice Address - Country:US
Practice Address - Phone:270-670-5357
Practice Address - Fax:844-688-4227
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201119769222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist