Provider Demographics
NPI:1588760771
Name:WALKER, MARI SULLIVAN (MA LICENSED PSYCHO)
Entity type:Individual
Prefix:MS
First Name:MARI
Middle Name:SULLIVAN
Last Name:WALKER
Suffix:
Gender:F
Credentials:MA LICENSED PSYCHO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 12TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2329
Mailing Address - Country:US
Mailing Address - Phone:304-425-9541
Mailing Address - Fax:304-487-6199
Practice Address - Street 1:102 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:MULLENS
Practice Address - State:WV
Practice Address - Zip Code:25882-1419
Practice Address - Country:US
Practice Address - Phone:304-294-5353
Practice Address - Fax:304-294-8627
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV203103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005489002Medicaid
WV0005489001Medicaid