Provider Demographics
NPI:1568795250
Name:MALLMANN, ANGELA R (PSYD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:R
Last Name:MALLMANN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 61
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-0061
Mailing Address - Country:US
Mailing Address - Phone:414-410-9905
Mailing Address - Fax:
Practice Address - Street 1:20700 WATERTOWN RD STE 100
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1800
Practice Address - Country:US
Practice Address - Phone:414-410-9905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
WI5291-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100031505Medicaid