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NPI Code Detail

MEDICARE: ANGELICA GRACE FORTENBERRY MSW, LCSW

MEDICARE: ANGELICA GRACE FORTENBERRY MSW, LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker2024000988MO

General Provider Information

NPI Number : 1629734322
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANGELICA GRACE FORTENBERRY MSW, LCSW
Provider Business Mailing Address
First Line : PO BOX 260
Second Line :
City : INDEPENDENCE
State : MO
Zip : 64051-0260
Country : US
Telephone Number : 816-254-3652
Fax Number :
Provider Business Practice Location Address
First Line : 17844 E 23RD ST S
Second Line :
City : INDEPENDENCE
State : MO
Zip : 64057-1840
Country : US
Telephone Number : 816-254-3652
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/17/2021
Last Update Date : 01/05/2026

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