Provider Demographics
NPI:1689560377
Name:WAL, MARNA SIMON (LSW)
Entity type:Individual
Prefix:
First Name:MARNA
Middle Name:SIMON
Last Name:WAL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16720 BRUNSWICK AVE SE APT 202
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-3988
Mailing Address - Country:US
Mailing Address - Phone:952-457-8466
Mailing Address - Fax:
Practice Address - Street 1:1136 W WILSON AVE APT 305
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-6201
Practice Address - Country:US
Practice Address - Phone:952-457-8466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.116631104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker