Provider Demographics
NPI:1588798953
Name:WALLEN, RANGELL LYNN (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:RANGELL
Middle Name:LYNN
Last Name:WALLEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BOONE RD
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-1894
Mailing Address - Country:US
Mailing Address - Phone:360-475-5168
Mailing Address - Fax:360-475-4596
Practice Address - Street 1:1 BOONE RD
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-1894
Practice Address - Country:US
Practice Address - Phone:360-475-5168
Practice Address - Fax:360-475-4596
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00004538101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional