Provider Demographics
NPI:1891143319
Name:WALLEN, CHARMAINE ANN MARIE
Entity Type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:ANN MARIE
Last Name:WALLEN
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 1:1470 BARNUM AVE
Mailing Address - Street 2:303
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-3237
Mailing Address - Country:US
Mailing Address - Phone:203-332-4940
Mailing Address - Fax:203-332-3219
Practice Address - Street 1:1470 BARNUM AVE
Practice Address - Street 2:303
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-3237
Practice Address - Country:US
Practice Address - Phone:203-332-4940
Practice Address - Fax:203-332-3219
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002842101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional