MEDICARE: MRS. MARYANN WALL

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	CW013986	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7073245	OTHER	PA	AETNA
2	2139104000	OTHER	PA	MAGELLAN MHS

General Provider Information

NPI Number	:	1730115536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARYANN WALL

Provider Business Mailing Address
First Line	:	58 NATHAN CT
Second Line	:
City	:	NEWTOWN
State	:	PA
Zip	:	18940-3430
Country	:	US
Telephone Number	:	215-624-5691
Fax Number	:	215-624-5816

Provider Business Practice Location Address
First Line	:	7340 JACKSON ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19136-4008
Country	:	US
Telephone Number	:	215-624-5691
Fax Number	:	215-624-5816

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

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	02/04/2011

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Directions to “ MRS. MARYANN WALL ” Practice Location

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