Provider Demographics
NPI:1992997068
Name:ANGELO, TONY WAYNE
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:WAYNE
Last Name:ANGELO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38251 POTATO CANYON RD
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-9554
Mailing Address - Country:US
Mailing Address - Phone:909-797-4228
Mailing Address - Fax:
Practice Address - Street 1:1025 S MOUNT VERNON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4226
Practice Address - Country:US
Practice Address - Phone:909-783-1473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic