=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396957411
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARJORIE A. WALSH LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 162 MILLER ST
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04915-6463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-338-1955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 85 DOLLOFF RD
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04951-3323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LC6892
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------