Provider Demographics
NPI:1073030714
Name:GOLDEN, ANGELA MARIE (MASTERS)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MARIE
Last Name:GOLDEN
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MASTERS
Mailing Address - Street 1:12029 78TH AVE W
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:IL
Mailing Address - Zip Code:61232-9667
Mailing Address - Country:US
Mailing Address - Phone:309-230-2308
Mailing Address - Fax:
Practice Address - Street 1:2221 10TH ST
Practice Address - Street 2:
Practice Address - City:SILVIS
Practice Address - State:IL
Practice Address - Zip Code:61282-2031
Practice Address - Country:US
Practice Address - Phone:309-792-2947
Practice Address - Fax:309-792-9658
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011414235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist