Healthcare Provider Details

I. General information

NPI: 1629385539
Provider Name (Legal Business Name): ANGEL M ROUBIN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S GARFIELD AVE
MONTEBELLO CA
90640-3810
US

IV. Provider business mailing address

51 BROAD ST
MIDDLETOWN CT
06457-3204
US

V. Phone/Fax

Practice location:
  • Phone: 323-869-9255
  • Fax:
Mailing address:
  • Phone: 860-358-3401
  • Fax: 860-358-3403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3554
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: