Provider Demographics
NPI:1497527451
Name:WHALEN, MARY ROSE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ROSE
Last Name:WHALEN
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 1:1307 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50316-4019
Mailing Address - Country:US
Mailing Address - Phone:937-478-1853
Mailing Address - Fax:
Practice Address - Street 1:1307 E 17TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-4019
Practice Address - Country:US
Practice Address - Phone:937-478-1853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA112483104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker