MEDICARE: ANGEL DAVID PSYD

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	071.011110	IL
2	103T00000X	Psychologist	4120	OR

General Provider Information

NPI Number	:	1639687205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGEL DAVID PSYD

Provider Business Mailing Address
First Line	:	950 LEE ST STE 105
Second Line	:
City	:	DES PLAINES
State	:	IL
Zip	:	60016-6556
Country	:	US
Telephone Number	:	877-486-4140
Fax Number	:

Provider Business Practice Location Address
First Line	:	1750 BLANKENSHIP RD STE 400
Second Line	:
City	:	WEST LINN
State	:	OR
Zip	:	97068-5102
Country	:	US
Telephone Number	:	503-659-5515
Fax Number	:

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

Provider Enumeration Date	:	01/17/2018
Last Update Date	:	12/17/2025

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