Provider Demographics
NPI:1225026610
Name:SUTO-WALTERS, MARLENE ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARLENE
Middle Name:ANN
Last Name:SUTO-WALTERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:MARLENE
Other - Middle Name:ANN
Other - Last Name:SUTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:110 BOWMAN RD
Mailing Address - Street 2:
Mailing Address - City:ROCKWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:15557-6720
Mailing Address - Country:US
Mailing Address - Phone:814-444-2893
Mailing Address - Fax:
Practice Address - Street 1:419 STOYSTOWN RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501-6945
Practice Address - Country:US
Practice Address - Phone:814-444-2893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW 0150881041C0700X
PA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022638450004Medicaid
PA1022638450004Medicaid