Provider Demographics
NPI:1205283439
Name:HEALY, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:HEALY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 MILLSTREAM LN
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-8274
Mailing Address - Country:US
Mailing Address - Phone:815-685-6640
Mailing Address - Fax:
Practice Address - Street 1:336 MILLSTREAM LN
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-8274
Practice Address - Country:US
Practice Address - Phone:815-685-6640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILR200-0168-7970171W00000X
IL1-16-23375103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171W00000XOther Service ProvidersContractor