Provider Demographics
NPI:1891981593
Name:MARTY, ANGIE RACHELLE (LADC)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:RACHELLE
Last Name:MARTY
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:RACHELLE
Other - Last Name:MARTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3817 PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6017 BIRCHWOOD RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2007
Practice Address - Country:US
Practice Address - Phone:651-354-5455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2022-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
MN304564101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant