Healthcare Provider Details

I. General information

NPI: 1053016063
Provider Name (Legal Business Name): ANGELA COLEGROVE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2023
Last Update Date: 03/31/2023
Certification Date: 03/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 COLLEGE AVE
ELMIRA NY
14901-1169
US

IV. Provider business mailing address

76 VETERANS AVE
BATH NY
14810-0810
US

V. Phone/Fax

Practice location:
  • Phone: 570-418-0644
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number082793
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: