Healthcare Provider Details

I. General information

NPI: 1154668515
Provider Name (Legal Business Name): MICHAEL ANTHONY ANGELO LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2013
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MONROE AVE NW STE 400
GRAND RAPIDS MI
49503-2293
US

IV. Provider business mailing address

6430 OLD HUNTERS RUN
ROCKFORD IL
61114-7812
US

V. Phone/Fax

Practice location:
  • Phone: 331-575-5035
  • Fax:
Mailing address:
  • Phone: 331-575-5035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.009518
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401018853
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: