Provider Demographics
NPI:1649488529
Name:MOONEYHAM, ANGIE MARIE (MS LMFT)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:MARIE
Last Name:MOONEYHAM
Suffix:
Gender:F
Credentials:MS LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 E 2ND ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4119
Mailing Address - Country:US
Mailing Address - Phone:316-685-9311
Mailing Address - Fax:316-685-6101
Practice Address - Street 1:1421 E 2ND ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4119
Practice Address - Country:US
Practice Address - Phone:316-685-9311
Practice Address - Fax:316-685-6101
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLMFT 651106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist