Provider Demographics
NPI:1821647470
Name:WALERYSZAK, KATHLEEN AMANDA (LICSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:AMANDA
Last Name:WALERYSZAK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 RIDGEWOOD DR # A
Mailing Address - Street 2:
Mailing Address - City:KITTERY
Mailing Address - State:ME
Mailing Address - Zip Code:03904-1046
Mailing Address - Country:US
Mailing Address - Phone:207-337-0456
Mailing Address - Fax:
Practice Address - Street 1:426 STATE ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-4049
Practice Address - Country:US
Practice Address - Phone:707-654-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH22611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical