Provider Demographics
NPI:1952712556
Name:ERTL, ANGELA (LCSW)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:ERTL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:STE 5
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6511
Mailing Address - Country:US
Mailing Address - Phone:800-438-1772
Mailing Address - Fax:262-293-9737
Practice Address - Street 1:17100 W NORTH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4436
Practice Address - Country:US
Practice Address - Phone:800-438-1772
Practice Address - Fax:262-293-9737
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-16
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4615104100000X
WI8508-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker