Provider Demographics
NPI:1487115036
Name:HOWARD, ANGENIQUE CHEREE
Entity type:Individual
Prefix:
First Name:ANGENIQUE
Middle Name:CHEREE
Last Name:HOWARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 E CLIVEDEN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-3946
Mailing Address - Country:US
Mailing Address - Phone:215-960-5066
Mailing Address - Fax:
Practice Address - Street 1:4700 LEIPER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-3223
Practice Address - Country:US
Practice Address - Phone:215-960-5066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAA7443052103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4700OtherMENTAL HEALTH
PA4700Medicaid