=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255768206
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGELADAWN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2013
-----------------------------------------------------
Last Update Date | 10/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14182 WEEPING CHERRY DR
-----------------------------------------------------
City | FISHERS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46038-7471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-453-0503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14182 WEEPING CHERRY DR
-----------------------------------------------------
City | FISHERS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46038-7471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MFTA
-----------------------------------------------------
Name | MS. ANGELA FORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-453-0503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 8500011A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------