Provider Demographics
NPI:1790218626
Name:WALSH-SLACK, EMILY JANE (LSW)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:JANE
Last Name:WALSH-SLACK
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 1:19 STANTON AVE
Mailing Address - Street 2:
Mailing Address - City:BORDENTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08505-1924
Mailing Address - Country:US
Mailing Address - Phone:609-649-2532
Mailing Address - Fax:
Practice Address - Street 1:19 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2172
Practice Address - Country:US
Practice Address - Phone:856-985-9091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ45SL06211100104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker