Provider Demographics
NPI:1639108558
Name:MOUSE, ANGELA A (LICSW)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:A
Last Name:MOUSE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:S
Other - Last Name:AMICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:PO BOX 7310
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25356-0310
Mailing Address - Country:US
Mailing Address - Phone:304-776-7606
Mailing Address - Fax:304-776-7636
Practice Address - Street 1:100 PEYTON WAY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314
Practice Address - Country:US
Practice Address - Phone:304-720-8466
Practice Address - Fax:304-720-8463
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP000803681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVDP00080368OtherWV SOCIAL WORK LICENSE
WVDP00080368OtherWV SOCIAL WORK LICENSE