Provider Demographics
NPI:1811205792
Name:WILSON, ANGELA (LISW)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 COURT AVE
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IA
Mailing Address - Zip Code:52301-1438
Mailing Address - Country:US
Mailing Address - Phone:319-800-8522
Mailing Address - Fax:
Practice Address - Street 1:1024 COURT AVE
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IA
Practice Address - Zip Code:52301-1438
Practice Address - Country:US
Practice Address - Phone:319-777-9268
Practice Address - Fax:319-359-4034
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA064881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical