Provider Demographics
NPI:1669061255
Name:ALVAREZ TITUS, ANGELICA GRACE
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:GRACE
Last Name:ALVAREZ TITUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 CLARENCE DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-5582
Mailing Address - Country:US
Mailing Address - Phone:408-636-3665
Mailing Address - Fax:
Practice Address - Street 1:4737 S AFTON PL STE A
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2317
Practice Address - Country:US
Practice Address - Phone:208-417-0623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-7880101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLPC-7880Medicaid