Provider Demographics
NPI:1851603344
Name:WALRATH, JEREMY A (BSW, MA, LBS)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:A
Last Name:WALRATH
Suffix:
Gender:M
Credentials:BSW, MA, LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 PLAZA LN
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1766
Mailing Address - Country:US
Mailing Address - Phone:570-724-7142
Mailing Address - Fax:570-724-6771
Practice Address - Street 1:62 PLAZA LN
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1766
Practice Address - Country:US
Practice Address - Phone:570-724-7142
Practice Address - Fax:570-724-6771
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
PABH006787101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst