Provider Demographics
NPI:1093891871
Name:WALLERSTEIN, PATRICIA GALE (MSW LICSW)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:GALE
Last Name:WALLERSTEIN
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 10TH STREET
Mailing Address - Street 2:
Mailing Address - City:NEWBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01951
Mailing Address - Country:US
Mailing Address - Phone:978-463-6901
Mailing Address - Fax:
Practice Address - Street 1:100 MAIN STREET
Practice Address - Street 2:SUITE 11
Practice Address - City:AMESBURY
Practice Address - State:MA
Practice Address - Zip Code:01913
Practice Address - Country:US
Practice Address - Phone:978-388-5311
Practice Address - Fax:978-388-5571
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10226521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA102265OtherTUFTS
MAPP0352OtherBCBS
MA1890247Medicaid
MAP22215Medicare ID - Type Unspecified