Provider Demographics
NPI:1073636874
Name:WACHTENHEIM, MARION LYNN (MSW)
Entity Type:Individual
Prefix:MS
First Name:MARION
Middle Name:LYNN
Last Name:WACHTENHEIM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 PARIS ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-6129
Mailing Address - Country:US
Mailing Address - Phone:401-475-0785
Mailing Address - Fax:
Practice Address - Street 1:172 E CUSHING ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2255
Practice Address - Country:US
Practice Address - Phone:401-273-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2010-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW006781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI809003222Medicare ID - Type UnspecifiedPART B PROVIDER