Provider Demographics
NPI:1003502428
Name:TRUDEAU-WALLS, MARILYN ASHLEIGH (LMSW)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:ASHLEIGH
Last Name:TRUDEAU-WALLS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 PARK BRG
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-7212
Mailing Address - Country:US
Mailing Address - Phone:678-575-8384
Mailing Address - Fax:
Practice Address - Street 1:2727 PACES FERRY RD SE STE 260
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-4053
Practice Address - Country:US
Practice Address - Phone:678-758-0616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW009533104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker