Provider Demographics
NPI:1164763413
Name:DEWAARD, ANGIE KAY (LPC)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:KAY
Last Name:DEWAARD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 E BRIDGE ST APT 12
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-2234
Mailing Address - Country:US
Mailing Address - Phone:641-780-2741
Mailing Address - Fax:
Practice Address - Street 1:320 N EISENHOWER AVE
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-1521
Practice Address - Country:US
Practice Address - Phone:641-424-2391
Practice Address - Fax:641-424-0783
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001615101YA0400X
TX81764101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)