Provider Demographics
NPI:1053784371
Name:PELL, ANGELA KRYSTAL
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:KRYSTAL
Last Name:PELL
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 1:527 W ALDER ST APT D106
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4045
Mailing Address - Country:US
Mailing Address - Phone:484-792-1978
Mailing Address - Fax:
Practice Address - Street 1:4210 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1035
Practice Address - Country:US
Practice Address - Phone:406-728-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional