Provider Demographics
NPI:1912730417
Name:CHAN, ANGELICA KEIKO (MS, CF-SLP)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:KEIKO
Last Name:CHAN
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N BLANDENA ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2872
Mailing Address - Country:US
Mailing Address - Phone:925-337-9477
Mailing Address - Fax:
Practice Address - Street 1:5208 NE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1074
Practice Address - Country:US
Practice Address - Phone:925-337-9477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist