Healthcare Provider Details

I. General information

NPI: 1629734322
Provider Name (Legal Business Name): ANGELICA GRACE FORTENBERRY MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELICA GRACE FILLINGANE

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17844 E 23RD ST S
INDEPENDENCE MO
64057-1840
US

IV. Provider business mailing address

PO BOX 260
INDEPENDENCE MO
64051-0260
US

V. Phone/Fax

Practice location:
  • Phone: 816-254-3652
  • Fax:
Mailing address:
  • Phone: 816-254-3652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2024000988
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: