Provider Demographics
NPI:1053008094
Name:TINDLE, ANGELICA EM
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:EM
Last Name:TINDLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGELICA
Other - Middle Name:SONYTHA
Other - Last Name:EM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:835 W HARNEY LN APT 2
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-7033
Mailing Address - Country:US
Mailing Address - Phone:209-518-4410
Mailing Address - Fax:
Practice Address - Street 1:835 W HARNEY LN APT 2
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-7033
Practice Address - Country:US
Practice Address - Phone:209-518-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126800000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No126800000XDental ProvidersDental Assistant