Provider Demographics
NPI:1902408255
Name:ANGULO, DEIDRA WILLIAMS (PSD, LISAC)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:WILLIAMS
Last Name:ANGULO
Suffix:
Gender:F
Credentials:PSD, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5704 E GABLE AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-6714
Mailing Address - Country:US
Mailing Address - Phone:602-524-1986
Mailing Address - Fax:
Practice Address - Street 1:5704 E GABLE AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6714
Practice Address - Country:US
Practice Address - Phone:602-524-1986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11653101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)