Provider Demographics
NPI:1144377540
Name:GLICK, ANGELA DAWN (LCP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:DAWN
Last Name:GLICK
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:ANGEL
Other - Middle Name:DAWN
Other - Last Name:GLICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:701 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-1699
Mailing Address - Country:US
Mailing Address - Phone:304-369-1230
Mailing Address - Fax:304-369-6036
Practice Address - Street 1:306 MAIN ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3906
Practice Address - Country:US
Practice Address - Phone:304-752-7707
Practice Address - Fax:304-752-0772
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV776103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9202037000Medicaid
WV001715137OtherBLUECROSS SHIELD PROVIDER