Provider Demographics
NPI:1659522100
Name:WALBURN, MARYLOU MICHELLE (LMSW)
Entity Type:Individual
Prefix:
First Name:MARYLOU
Middle Name:MICHELLE
Last Name:WALBURN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2568 E STEWART RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-8557
Mailing Address - Country:US
Mailing Address - Phone:989-708-1338
Mailing Address - Fax:
Practice Address - Street 1:2568 E STEWART RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-8557
Practice Address - Country:US
Practice Address - Phone:989-708-1338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010859941041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI13676296OtherCAQH