Healthcare Provider Details

I. General information

NPI: 1861308074
Provider Name (Legal Business Name): ANGELICA FAMILY WELLNESS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 EXECUTIVE PARK NW STE A
CLEVELAND TN
37312-2770
US

IV. Provider business mailing address

9511 SILVER STONE LN
OOLTEWAH TN
37363-3008
US

V. Phone/Fax

Practice location:
  • Phone: 951-776-6752
  • Fax:
Mailing address:
  • Phone: 951-776-6752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: ANGELICA SOTO
Title or Position: DIRECTO
Credential: PSYD
Phone: 951-776-6752