Provider Demographics
NPI:1093820318
Name:ANGEL, CLYDE T (DMIN)
Entity type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:T
Last Name:ANGEL
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:DR
Other - First Name:CLYDE
Other - Middle Name:THOMAS
Other - Last Name:ANGEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMIN
Mailing Address - Street 1:6025 BRANDEN HILL LN
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-2225
Mailing Address - Country:US
Mailing Address - Phone:678-765-0019
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:404-329-2235
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral