Provider Demographics
NPI:1194920306
Name:WINDHAM, ANGEL (LCSW)
Entity type:Individual
Prefix:DR
First Name:ANGEL
Middle Name:
Last Name:WINDHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:ANGEL
Other - Middle Name:
Other - Last Name:BEATTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:1075 EASTON AVENUE TOWER 1 SUITE 1
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873
Mailing Address - Country:US
Mailing Address - Phone:732-705-9777
Mailing Address - Fax:732-213-0916
Practice Address - Street 1:1075 EASTON AVENUE TOWER 1 SUITE 1
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873
Practice Address - Country:US
Practice Address - Phone:732-705-9777
Practice Address - Fax:732-213-0916
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05258500104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ44SL05258500Medicare UPIN