Healthcare Provider Details

I. General information

NPI: 1609384593
Provider Name (Legal Business Name): ANGELA M MOTT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2018
Last Update Date: 07/05/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 W CENTRE AVE STE 109
PORTAGE MI
49024-5339
US

IV. Provider business mailing address

1611 W CENTRE AVE STE 109
PORTAGE MI
49024-5339
US

V. Phone/Fax

Practice location:
  • Phone: 269-350-4377
  • Fax:
Mailing address:
  • Phone: 269-350-4377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401018687
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: