Provider Demographics
NPI:1407922545
Name:WANNER, MARILYN ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:ANN
Last Name:WANNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S WHITING ST
Mailing Address - Street 2:SUITE 605
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-7100
Mailing Address - Country:US
Mailing Address - Phone:703-593-1784
Mailing Address - Fax:703-212-7498
Practice Address - Street 1:205 S WHITING ST
Practice Address - Street 2:SUITE 605
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-7100
Practice Address - Country:US
Practice Address - Phone:703-593-1784
Practice Address - Fax:703-212-7498
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040017171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA031761OtherVALUE OPTIONS
VA210273OtherBLUE CROSS & HEATHKEEPERS
VA292756OtherAMERIGROUP
VA117005OtherKAISER
VA11234233OtherAETNA
VAH1860001OtherCARE FIRST BLUE CROSS
VA223141OtherANTHEM BLUE CROSS
VA11234233OtherAETNA