=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003006966
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL ANTHONY D'ANGELO JR. PSY.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2007
-----------------------------------------------------
Last Update Date | 08/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98431-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-968-5370
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98431-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-968-5370
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY20354
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY60351579
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------