Provider Demographics
NPI:1992360531
Name:PENNELL, ANGELA (APSW, CSAC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:PENNELL
Suffix:
Gender:F
Credentials:APSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 E ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2410
Mailing Address - Country:US
Mailing Address - Phone:608-289-7064
Mailing Address - Fax:
Practice Address - Street 1:1820 CENTER AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-2802
Practice Address - Country:US
Practice Address - Phone:608-755-1475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18191-130101YA0400X
WI134074104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1124242177Medicaid