Provider Demographics
NPI:1528109071
Name:WALL-KETELHUT, MARLANA KAY (MA, LLPC, LBSW)
Entity type:Individual
Prefix:MRS
First Name:MARLANA
Middle Name:KAY
Last Name:WALL-KETELHUT
Suffix:
Gender:F
Credentials:MA, LLPC, LBSW
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Mailing Address - Street 1:42292 MAC RAE DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-2566
Mailing Address - Country:US
Mailing Address - Phone:586-996-1171
Mailing Address - Fax:
Practice Address - Street 1:6555 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-4511
Practice Address - Country:US
Practice Address - Phone:586-783-8100
Practice Address - Fax:586-469-7925
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008694101YP2500X
MI6802066714104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker