Healthcare Provider Details

I. General information

NPI: 1124582549
Provider Name (Legal Business Name): ANGELA HEGGBLAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 BROAD AVE
GULFPORT MS
39501-3603
US

IV. Provider business mailing address

1600 BROAD AVE
GULFPORT MS
39501-3603
US

V. Phone/Fax

Practice location:
  • Phone: 228-865-1719
  • Fax: 228-865-1780
Mailing address:
  • Phone: 228-865-1719
  • Fax: 228-865-1780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: