Healthcare Provider Details

I. General information

NPI: 1386057842
Provider Name (Legal Business Name): MARY ELLEN WAITKUS LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 06/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1479 COLLINS AVE
MARYSVILLE OH
43040-8808
US

IV. Provider business mailing address

1479 COLLINS AVE
MARYSVILLE OH
43040-8808
US

V. Phone/Fax

Practice location:
  • Phone: 937-642-1065
  • Fax:
Mailing address:
  • Phone: 937-642-1065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI10175
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: