Provider Demographics
NPI:1619073343
Name:MARI SULLIVAN WALKER INC
Entity Type:Organization
Organization Name:MARI SULLIVAN WALKER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARI
Authorized Official - Middle Name:SULLIVAN
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED PSYCHOLOGIS
Authorized Official - Phone:304-732-9132
Mailing Address - Street 1:RT#10 MAIN STREET P.O. BOX 123
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:24874-0123
Mailing Address - Country:US
Mailing Address - Phone:304-732-9132
Mailing Address - Fax:304-732-6589
Practice Address - Street 1:RT#10 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:WV
Practice Address - Zip Code:24874-0123
Practice Address - Country:US
Practice Address - Phone:304-732-9132
Practice Address - Fax:304-732-6589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV203103T00000X, 103TB0200X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVLICENSE # 203OtherPSYCHOLOGIST LICENSE
WV0165341000Medicaid
WV0165341000Medicaid