MEDICARE: MARILYN WANYO LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1262	NH
2	1041C0700X	Clinical Social Worker	LC6877	ME

General Provider Information

NPI Number	:	1215953682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILYN WANYO LICSW

Provider Business Mailing Address
First Line	:	370 PORTSMOUTH AVE
Second Line	:
City	:	GREENLAND
State	:	NH
Zip	:	03840-2252
Country	:	US
Telephone Number	:	603-431-3250
Fax Number	:

Provider Business Practice Location Address
First Line	:	370 PORTSMOUTH AVE
Second Line	:
City	:	GREENLAND
State	:	NH
Zip	:	03840-2252
Country	:	US
Telephone Number	:	603-431-3250
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	07/08/2007

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