Basic Information
Provider Information
NPI: 1003006966
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: D'ANGELO
FirstName: MICHAEL
MiddleName: ANTHONY
NamePrefix: DR.
NameSuffix: JR.
Credential: PSY.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: MADIGAN ARMY MEDICAL CENTER 9040 REID ST
Address2:  
City: TACOMA
State: WA
PostalCode: 984310001
CountryCode: US
TelephoneNumber: 2539685370
FaxNumber:  
Practice Location
Address1: MADIGAN ARMY MEDICAL CENTER 9040 REID ST
Address2:  
City: TACOMA
State: WA
PostalCode: 984310001
CountryCode: US
TelephoneNumber: 2539685370
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/27/2007
LastUpdateDate: 02/20/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103TC0700XPY60351579WAY Behavioral Health & Social Service ProvidersPsychologistClinical
103TC0700XPSY20354CAN Behavioral Health & Social Service ProvidersPsychologistClinical

No ID Information.


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