Provider Demographics
NPI:1104025428
Name:WALDER, MARCELLA GORDON (MSW)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:GORDON
Last Name:WALDER
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 1:16 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-1904
Mailing Address - Country:US
Mailing Address - Phone:301-474-2146
Mailing Address - Fax:301-474-1544
Practice Address - Street 1:16 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-1904
Practice Address - Country:US
Practice Address - Phone:301-474-2146
Practice Address - Fax:301-474-1544
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR24698Medicare UPIN