Healthcare Provider Details

I. General information

NPI: 1912230756
Provider Name (Legal Business Name): ANGELA RENEE WALLICK LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA RENEE BLAIR LBSW

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E WASHINGTON ST
CLARINDA IA
51632-1625
US

IV. Provider business mailing address

215 E WASHINGTON ST
CLARINDA IA
51632-1625
US

V. Phone/Fax

Practice location:
  • Phone: 712-542-3501
  • Fax: 712-542-4725
Mailing address:
  • Phone: 712-542-3501
  • Fax: 712-542-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06279
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: