Healthcare Provider Details

I. General information

NPI: 1669594784
Provider Name (Legal Business Name): ANGELA E VANG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 COLLEGE AVE
SOMERVILLE MA
02144-1957
US

IV. Provider business mailing address

11 PARK STREET CT
MEDFORD MA
02155-3902
US

V. Phone/Fax

Practice location:
  • Phone: 617-629-6628
  • Fax: 617-629-4454
Mailing address:
  • Phone: 617-512-7003
  • Fax: 617-629-4454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number214337
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: