Healthcare Provider Details

I. General information

NPI: 1740881044
Provider Name (Legal Business Name): ANGELIA EVANGELISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 AXTELL DR STE 100
TROY MI
48084-4400
US

IV. Provider business mailing address

1258 MORSE AVE
ROYAL OAK MI
48067-4514
US

V. Phone/Fax

Practice location:
  • Phone: 248-787-0855
  • Fax:
Mailing address:
  • Phone: 586-552-7626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6362009242
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: