Provider Demographics
NPI:1043965700
Name:WALPOLE, MARILYNNE SUE (CADC L CA)
Entity Type:Individual
Prefix:
First Name:MARILYNNE
Middle Name:SUE
Last Name:WALPOLE
Suffix:
Gender:F
Credentials:CADC L CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 1ST ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-0840
Mailing Address - Country:US
Mailing Address - Phone:707-498-1865
Mailing Address - Fax:
Practice Address - Street 1:2107 1ST ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-0840
Practice Address - Country:US
Practice Address - Phone:707-273-6395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACICA05000821101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANONEMedicaid