Basic Information
Provider Information | |||||||||
NPI: | 1962830265 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCNALLY-WERNETTE | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 10 | ||||||||
Address2: |   | ||||||||
City: | MASON | ||||||||
State: | MI | ||||||||
PostalCode: | 488540010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5176769788 | ||||||||
FaxNumber: | 5176763438 | ||||||||
Practice Location | |||||||||
Address1: | 211 MAPLE ST | ||||||||
Address2: |   | ||||||||
City: | BIG RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 493073215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9899445735 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2013 | ||||||||
LastUpdateDate: | 04/02/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401012948 | MI | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.