Provider Demographics
NPI:1548677990
Name:VINCENT, ANGELA (ATC, LAT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:VINCENT
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12219 GRIMSLEY DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-3156
Mailing Address - Country:US
Mailing Address - Phone:512-771-0790
Mailing Address - Fax:
Practice Address - Street 1:12219 GRIMSLEY DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-3156
Practice Address - Country:US
Practice Address - Phone:512-771-0790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT 21742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer