Healthcare Provider Details

I. General information

NPI: 1831947167
Provider Name (Legal Business Name): ANGELLE N NEWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELLE N HENSON OT

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 TROY RD
EDWARDSVILLE IL
62025-2540
US

IV. Provider business mailing address

2122 TROY RD
EDWARDSVILLE IL
62025-2540
US

V. Phone/Fax

Practice location:
  • Phone: 618-800-4620
  • Fax:
Mailing address:
  • Phone: 618-800-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2024016293
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056016004
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: