Provider Demographics
NPI:1427878990
Name:ANGULO, ADDISON RAE
Entity type:Individual
Prefix:
First Name:ADDISON
Middle Name:RAE
Last Name:ANGULO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ADDISON
Other - Middle Name:RAE
Other - Last Name:RUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2535 CAMINO DEL RIO S STE 303
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3757
Mailing Address - Country:US
Mailing Address - Phone:858-357-3556
Mailing Address - Fax:
Practice Address - Street 1:2535 CAMINO DEL RIO S STE 303
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3757
Practice Address - Country:US
Practice Address - Phone:858-357-3556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT123638106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist