Provider Demographics
NPI:1336697333
Name:CLOONAN WALSH, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CLOONAN WALSH
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 1:1913 WINDSONG DR
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60194-4417
Mailing Address - Country:US
Mailing Address - Phone:847-695-0484
Mailing Address - Fax:847-695-0387
Practice Address - Street 1:1913 WINDSONG DR
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60194-4417
Practice Address - Country:US
Practice Address - Phone:847-695-0484
Practice Address - Fax:847-695-0387
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL171MOOOOOXOtherCMS