Provider Demographics
NPI:1326479510
Name:POVLETICH, ANGELA (MS)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:POVLETICH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5007 S HOWELL AVE STE 350
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-6159
Mailing Address - Country:US
Mailing Address - Phone:262-789-1191
Mailing Address - Fax:
Practice Address - Street 1:5007 S HOWELL AVE STE 350
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-6159
Practice Address - Country:US
Practice Address - Phone:262-789-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5505-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42170300Medicaid