Provider Demographics
NPI:1245920826
Name:ANDERSON, ANGELA MARIE (MASTERS STUDENT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MASTERS STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 BRIDGEPORT AVE # 102
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-4662
Mailing Address - Country:US
Mailing Address - Phone:203-243-2459
Mailing Address - Fax:
Practice Address - Street 1:1635 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-1984
Practice Address - Country:US
Practice Address - Phone:203-333-3518
Practice Address - Fax:203-382-5589
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)