MEDICARE: DR. ANGELA GONNELLA PSY.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	TP173-095	NJ
2	103T00000X	Psychologist	35SI00610000	NJ

General Provider Information

NPI Number	:	1104339639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANGELA GONNELLA PSY.D

Provider Business Mailing Address
First Line	:	43 MANOR CRESCENT
Second Line	:
City	:	NEW BRUNSWICK
State	:	NJ
Zip	:	08901
Country	:	US
Telephone Number	:	201-919-8078
Fax Number	:

Provider Business Practice Location Address
First Line	:	748 MORRIS TPKE STE 209
Second Line	:
City	:	SHORT HILLS
State	:	NJ
Zip	:	07078-2617
Country	:	US
Telephone Number	:	551-226-9461
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2017
Last Update Date	:	06/24/2019

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