Provider Demographics
NPI:1215352059
Name:ANDEWAY, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:ANDEWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-2910
Mailing Address - Country:US
Mailing Address - Phone:641-682-8772
Mailing Address - Fax:641-682-1924
Practice Address - Street 1:110 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-2910
Practice Address - Country:US
Practice Address - Phone:641-682-8772
Practice Address - Fax:641-682-1924
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA072076101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1659353670OtherBLUE CROSS BLUE SHIELD
IA1659353670Medicaid