Provider Demographics
NPI:1275665770
Name:PROVENZANO SCHAUB, ANGELA
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:
Last Name:PROVENZANO SCHAUB
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:PO BOX 2884
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07091-2884
Mailing Address - Country:US
Mailing Address - Phone:908-232-4331
Mailing Address - Fax:
Practice Address - Street 1:318 ELM ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-3104
Practice Address - Country:US
Practice Address - Phone:908-232-4331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2008-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100238900103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ626182Medicare ID - Type Unspecified