Healthcare Provider Details

I. General information

NPI: 1710245808
Provider Name (Legal Business Name): MARYELLEN WALSH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2113 WABASH AVE
LINWOOD NJ
08221-1443
US

IV. Provider business mailing address

2113 WABASH AVE
LINWOOD NJ
08221-1443
US

V. Phone/Fax

Practice location:
  • Phone: 609-703-6318
  • Fax:
Mailing address:
  • Phone: 609-703-6318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SC05205800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: