Basic Information
| Provider Information | |||||||||
| NPI: | 1376732107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURTON | ||||||||
| FirstName: | ANGIE | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LISW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WIELAND | ||||||||
| OtherFirstName: | ANGIE | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LISW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7320 STATE ROUTE 108 STE A | ||||||||
| Address2: | |||||||||
| City: | WAUSEON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435678201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193353732 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7320 STATE ROUTE 108 STE A | ||||||||
| Address2: | |||||||||
| City: | WAUSEON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435678201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193353732 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2007 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | I.0009678 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.