Provider Demographics
NPI:1003219130
Name:WALLER, HELEN (BS)
Entity Type:Individual
Prefix:
First Name:HELEN
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12080 MENDEL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-2288
Mailing Address - Country:US
Mailing Address - Phone:386-631-1793
Mailing Address - Fax:
Practice Address - Street 1:12080 MENDEL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826
Practice Address - Country:US
Practice Address - Phone:386-631-1793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1690461740Medicaid