Provider Demographics
NPI:1992124192
Name:MUSILLA, ANGELA
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:MUSILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-7419
Mailing Address - Country:US
Mailing Address - Phone:918-815-4195
Mailing Address - Fax:
Practice Address - Street 1:1732 S KELLY AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3630
Practice Address - Country:US
Practice Address - Phone:405-844-8085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst