Provider Demographics
NPI:1538409883
Name:AUSTIN, ANGELIQUE MONIQUE (MS)
Entity type:Individual
Prefix:MS
First Name:ANGELIQUE
Middle Name:MONIQUE
Last Name:AUSTIN
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 1:5126 TERRA LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-9092
Mailing Address - Country:US
Mailing Address - Phone:850-619-3230
Mailing Address - Fax:
Practice Address - Street 1:6706 N 9TH AVE
Practice Address - Street 2:SUITE B-5
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-9303
Practice Address - Country:US
Practice Address - Phone:850-466-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-24
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008355300Medicaid