Provider Demographics
NPI:1912173246
Name:WALPOLE, MARYELLEN (MSSW)
Entity Type:Individual
Prefix:MS
First Name:MARYELLEN
Middle Name:
Last Name:WALPOLE
Suffix:
Gender:F
Credentials:MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 STILLSON RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-3103
Mailing Address - Country:US
Mailing Address - Phone:203-335-7000
Mailing Address - Fax:
Practice Address - Street 1:400 STILLSON RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-3103
Practice Address - Country:US
Practice Address - Phone:203-335-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0005481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT140000548CT01OtherANTHEM BLUE CROSS & BLUE SHIELD