=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326270257
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA JEAN FENSKE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2009
-----------------------------------------------------
Last Update Date | 01/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1530 S MAIN ST
-----------------------------------------------------
City | JOPLIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64804-0750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-437-4329
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13050 HICKORY DR
-----------------------------------------------------
City | NEOSHO
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-437-4329
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2009008980
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------