Provider Demographics
NPI:1013308329
Name:BUB, ANGELA (LCSW LICSW CCTP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BUB
Suffix:
Gender:F
Credentials:LCSW LICSW CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 BURNING TREE RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-2634
Mailing Address - Country:US
Mailing Address - Phone:218-623-1812
Mailing Address - Fax:
Practice Address - Street 1:4720 BURNING TREE RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-2634
Practice Address - Country:US
Practice Address - Phone:218-623-1812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70479104100000X
WI99951231041C0700X
MN292341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker