=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821696535
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGENA MOMBRUN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2020
-----------------------------------------------------
Last Update Date | 07/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 N 18TH ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19103-2707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-450-6598
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3700 CONSHOHOCKEN AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19131-2823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-235-8449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | PC012626
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------