Provider Demographics
NPI:1215953682
Name:WANYO, MARILYN (LICSW)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:WANYO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 PORTSMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:GREENLAND
Mailing Address - State:NH
Mailing Address - Zip Code:03840-2252
Mailing Address - Country:US
Mailing Address - Phone:603-431-3250
Mailing Address - Fax:
Practice Address - Street 1:370 PORTSMOUTH AVE
Practice Address - Street 2:
Practice Address - City:GREENLAND
Practice Address - State:NH
Practice Address - Zip Code:03840-2252
Practice Address - Country:US
Practice Address - Phone:603-431-3250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12621041C0700X
MELC68771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE8300Medicare ID - Type Unspecified