Provider Demographics
NPI:1114464864
Name:WALLEN, ELAINE
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:
Last Name:WALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N HIATUS RD
Mailing Address - Street 2:SUITE 140/161
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-3097
Mailing Address - Country:US
Mailing Address - Phone:954-333-8787
Mailing Address - Fax:954-333-8621
Practice Address - Street 1:1000 N HIATUS RD
Practice Address - Street 2:SUITE 140/161
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-3097
Practice Address - Country:US
Practice Address - Phone:954-333-8787
Practice Address - Fax:954-333-8621
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8383571041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool