Provider Demographics
NPI:1699252627
Name:NOVINE, ANGELA (MFT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:NOVINE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 BLAINE AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-2912
Mailing Address - Country:US
Mailing Address - Phone:262-914-1799
Mailing Address - Fax:
Practice Address - Street 1:200 S EXECUTIVE DR STE 101
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4216
Practice Address - Country:US
Practice Address - Phone:262-737-4552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI641-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist