Healthcare Provider Details

I. General information

NPI: 1215953682
Provider Name (Legal Business Name): MARILYN WANYO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 PORTSMOUTH AVE
GREENLAND NH
03840-2252
US

IV. Provider business mailing address

370 PORTSMOUTH AVE
GREENLAND NH
03840-2252
US

V. Phone/Fax

Practice location:
  • Phone: 603-431-3250
  • Fax:
Mailing address:
  • Phone: 603-431-3250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1262
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC6877
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: