Provider Demographics
NPI:1508149543
Name:WALENTOVIC, MARY JO ANN
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:ANN
Last Name:WALENTOVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY JO
Other - Middle Name:ANN
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:310 S PARKER ST
Mailing Address - Street 2:P.O. BOX 514
Mailing Address - City:MARINE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48039-3579
Mailing Address - Country:US
Mailing Address - Phone:810-887-2805
Mailing Address - Fax:
Practice Address - Street 1:310 S PARKER ST
Practice Address - Street 2:
Practice Address - City:MARINE CITY
Practice Address - State:MI
Practice Address - Zip Code:48039-3579
Practice Address - Country:US
Practice Address - Phone:810-887-2805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012278101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional