MEDICARE: DR. ROBERT DANGELO PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	31259	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2164946	OTHER	TX	COMPSYCH
2	10012380	OTHER	TX	AMERIGROUP
3	00083P	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1346228608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT DANGELO PSY.D.

Provider Business Mailing Address
First Line	:	4618 WOODSIDE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77023-1222
Country	:	US
Telephone Number	:	713-898-0661
Fax Number	:	206-984-9632

Provider Business Practice Location Address
First Line	:	3303 MAIN ST
Second Line	:	SUITE 304
City	:	HOUSTON
State	:	TX
Zip	:	77002-9322
Country	:	US
Telephone Number	:	713-898-0661
Fax Number	:	206-984-9632

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2006
Last Update Date	:	08/27/2007

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