Provider Demographics
NPI:1417418781
Name:WISTRICK, ANGELA (OTR)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WISTRICK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 GROVER ST STE B2
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-1539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:805 W ORCHARD DR STE 2
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1759
Practice Address - Country:US
Practice Address - Phone:360-354-5245
Practice Address - Fax:360-354-7796
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118169225X00000X
WAOT61635659225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist