Provider Demographics
NPI:1851304109
Name:MARSHALL, WANDA (LSW)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:MARSHALL
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 1:3941 COMMERCE AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1104
Mailing Address - Country:US
Mailing Address - Phone:215-481-5450
Mailing Address - Fax:
Practice Address - Street 1:3941 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1104
Practice Address - Country:US
Practice Address - Phone:215-481-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CW0126731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00127Medicare UPIN