Basic Information
Provider Information | |||||||||
NPI: | 1639321060 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANGERT | ||||||||
FirstName: | GWENDOLYN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSY.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ANGERT | ||||||||
OtherFirstName: | GWEN | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PSY.D | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7286 | ||||||||
Address2: |   | ||||||||
City: | VISALIA | ||||||||
State: | CA | ||||||||
PostalCode: | 932907286 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5596236675 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1039 MURRAY AVE STE 220 | ||||||||
Address2: |   | ||||||||
City: | SAN LUIS OBISPO | ||||||||
State: | CA | ||||||||
PostalCode: | 934052058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8052502996 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/16/2008 | ||||||||
LastUpdateDate: | 06/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.