Provider Demographics
NPI:1376732107
Name:BURTON, ANGIE ELLEN (LISW)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:ELLEN
Last Name:BURTON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:ELLEN
Other - Last Name:WIELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:7320 STATE ROUTE 108 STE A
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-8201
Mailing Address - Country:US
Mailing Address - Phone:419-335-3732
Mailing Address - Fax:
Practice Address - Street 1:7320 STATE ROUTE 108 STE A
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-8201
Practice Address - Country:US
Practice Address - Phone:419-335-3732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0009678101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHWISW26881Medicare PIN