Provider Demographics
NPI:1821696535
Name:MOMBRUN, ANGENA (LPC)
Entity Type:Individual
Prefix:
First Name:ANGENA
Middle Name:
Last Name:MOMBRUN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 CONSHOHOCKEN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-2823
Mailing Address - Country:US
Mailing Address - Phone:267-235-8449
Mailing Address - Fax:
Practice Address - Street 1:100 N 18TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-2707
Practice Address - Country:US
Practice Address - Phone:484-450-6598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC012626101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty