Healthcare Provider Details

I. General information

NPI: 1205572237
Provider Name (Legal Business Name): KAITLYN ANNE WALLNER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 05/11/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3408 PARK AVE
WANTAGH NY
11793-3702
US

IV. Provider business mailing address

3408 PARK AVE
WANTAGH NY
11793-3702
US

V. Phone/Fax

Practice location:
  • Phone: 516-221-2123
  • Fax: 516-221-2124
Mailing address:
  • Phone: 516-221-2123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number099085-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: