Provider Demographics
NPI:1760458947
Name:WALLING, MARY KATHRYN (PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:WALLING
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHRYN
Other - Last Name:GOODSPEED
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-384-7900
Mailing Address - Fax:319-384-7901
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-384-7900
Practice Address - Fax:319-384-7901
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00466103T00000X
IA00994103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA02643OtherWELLMARK BCBS
IA0480244Medicaid
IA0480244Medicaid
I16583Medicare PIN