Provider Demographics
NPI:1861623258
Name:KLEBACK, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:KLEBACK
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 1:40 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:PA
Mailing Address - Zip Code:18644-1617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 W 7TH ST
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:PA
Practice Address - Zip Code:18644-1617
Practice Address - Country:US
Practice Address - Phone:570-693-3569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARTO0000732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer