Provider Demographics
NPI:1710245808
Name:WALSH, MARYELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2113 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-1443
Mailing Address - Country:US
Mailing Address - Phone:609-703-6318
Mailing Address - Fax:
Practice Address - Street 1:2113 WABASH AVE
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1443
Practice Address - Country:US
Practice Address - Phone:609-703-6318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05205800104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker