MEDICARE: ANGEL THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH12979	FL

General Provider Information

NPI Number	:	1437684438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGEL THERAPY, LLC

Provider Business Mailing Address
First Line	:	7203 PINE FOREST RD
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32526-3908
Country	:	US
Telephone Number	:	850-619-3230
Fax Number	:

Provider Business Practice Location Address
First Line	:	5126 TERRA LAKE CIR
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32507-9092
Country	:	US
Telephone Number	:	850-619-3230
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. ANGELIQUE M AUSTIN
Credential	:	LMHC
Telephone Number	:	850-619-3230

Provider Enumeration Date	:	04/27/2017
Last Update Date	:	04/27/2017

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Directions to “ANGEL THERAPY, LLC ” Practice Location

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