Provider Demographics
NPI:1801658810
Name:VANBLARICUM, ANGELA NICHOLE (LLC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:NICHOLE
Last Name:VANBLARICUM
Suffix:
Gender:F
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2444
Mailing Address - Country:US
Mailing Address - Phone:989-779-8999
Mailing Address - Fax:
Practice Address - Street 1:411 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2444
Practice Address - Country:US
Practice Address - Phone:989-779-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023339101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor