Healthcare Provider Details

I. General information

NPI: 1639687205
Provider Name (Legal Business Name): ANGEL DAVID PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 BLANKENSHIP RD STE 400
WEST LINN OR
97068-5102
US

IV. Provider business mailing address

950 LEE ST STE 105
DES PLAINES IL
60016-6556
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-5515
  • Fax:
Mailing address:
  • Phone: 877-486-4140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.011110
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4120
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: