Provider Demographics
NPI:1730115536
Name:WALL, MARYANN
Entity Type:Individual
Prefix:MRS
First Name:MARYANN
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 NATHAN CT
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-3430
Mailing Address - Country:US
Mailing Address - Phone:215-624-5691
Mailing Address - Fax:215-624-5816
Practice Address - Street 1:7340 JACKSON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136-4008
Practice Address - Country:US
Practice Address - Phone:215-624-5691
Practice Address - Fax:215-624-5816
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0139861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7073245OtherAETNA
PA2139104000OtherMAGELLAN MHS
PA7073245OtherAETNA