MEDICARE: ANGELINA SDAO CGC

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	170300000X	Genetic Counselor (M.S.)	7201000491	MI

General Provider Information

NPI Number	:	1518722750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELINA SDAO CGC

Provider Business Mailing Address
First Line	:	18181 OAKWOOD BLVD STE 102G
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-3996
Country	:	US
Telephone Number	:	313-593-8482
Fax Number	:

Provider Business Practice Location Address
First Line	:	18181 OAKWOOD BLVD STE 102G
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-3996
Country	:	US
Telephone Number	:	313-593-8482
Fax Number	:

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

Provider Enumeration Date	:	02/16/2024
Last Update Date	:	02/16/2024

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