Healthcare Provider Details

I. General information

NPI: 1154490936
Provider Name (Legal Business Name): ANGELIA K DUSSIA MA, PCC, CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 01/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 MEDWAY NEW CARLISLE RD
MEDWAY OH
45341-9744
US

IV. Provider business mailing address

2675 MEDWAY NEW CARLISLE RD
MEDWAY OH
45341-9744
US

V. Phone/Fax

Practice location:
  • Phone: 937-849-1257
  • Fax: 937-849-1336
Mailing address:
  • Phone: 937-849-1257
  • Fax: 937-849-1336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC0500552
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: