Provider Demographics
NPI:1558696195
Name:LUCIANO-CHAMPOUX, ANGELA (PT)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:
Last Name:LUCIANO-CHAMPOUX
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 LEROY AVE
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08009-2125
Mailing Address - Country:US
Mailing Address - Phone:856-340-1518
Mailing Address - Fax:
Practice Address - Street 1:70 LEROY AVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08009-2125
Practice Address - Country:US
Practice Address - Phone:856-340-1518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA004866002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic