Provider Demographics
NPI:1699935205
Name:CLACK, ANGELA ROMAN (PSYD, LPC)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:ROMAN
Last Name:CLACK
Suffix:
Gender:F
Credentials:PSYD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 LIBERTY PL
Mailing Address - Street 2:LAKESIDE BUSINESS PARK
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-5707
Mailing Address - Country:US
Mailing Address - Phone:856-875-5335
Mailing Address - Fax:856-875-5336
Practice Address - Street 1:2005 LIBERTY PL
Practice Address - Street 2:2005
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-5707
Practice Address - Country:US
Practice Address - Phone:856-875-5335
Practice Address - Fax:856-875-5336
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00323700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional