Provider Demographics
NPI:1417627241
Name:ILLIG, ANGELA MARIE (MS, LPC, NCC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:ILLIG
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 748465
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8465
Mailing Address - Country:US
Mailing Address - Phone:855-284-7483
Mailing Address - Fax:
Practice Address - Street 1:1215 N GREENGATE RD STE D
Practice Address - Street 2:
Practice Address - City:JEANNETTE
Practice Address - State:PA
Practice Address - Zip Code:15644-4081
Practice Address - Country:US
Practice Address - Phone:724-832-1700
Practice Address - Fax:724-853-6704
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
PAPC016849101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor