Provider Demographics
NPI:1215139050
Name:VANCE, ANGEL MARIE (PTA)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:MARIE
Last Name:VANCE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19977 HUDSON BAY
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1493
Mailing Address - Country:US
Mailing Address - Phone:586-416-1990
Mailing Address - Fax:
Practice Address - Street 1:1331 TRUMBULL ST STE 100
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48216-1376
Practice Address - Country:US
Practice Address - Phone:313-962-9050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04870225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH04870OtherOHIO PHYSICAL THERAPY