Provider Demographics
NPI:1386057842
Name:WAITKUS, MARY ELLEN (LISW-S)
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:WAITKUS
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1479 COLLINS AVE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-8808
Mailing Address - Country:US
Mailing Address - Phone:937-642-1065
Mailing Address - Fax:
Practice Address - Street 1:1479 COLLINS AVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-8808
Practice Address - Country:US
Practice Address - Phone:937-642-1065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI101751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical