Provider Demographics
NPI:1366771578
Name:ANGUS, KATHLEEN A
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:ANGUS
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 1:411 E CONGRESS PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6247
Mailing Address - Country:US
Mailing Address - Phone:815-459-3810
Mailing Address - Fax:
Practice Address - Street 1:411 E CONGRESS PKWY STE B
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6247
Practice Address - Country:US
Practice Address - Phone:815-459-3810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1638843103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool