Provider Demographics
NPI:1013020957
Name:WALLER, DONNIE M (LSW)
Entity Type:Individual
Prefix:MR
First Name:DONNIE
Middle Name:M
Last Name:WALLER
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 220B
Mailing Address - Street 2:
Mailing Address - City:MEEKER
Mailing Address - State:OK
Mailing Address - Zip Code:74855-9305
Mailing Address - Country:US
Mailing Address - Phone:405-214-9667
Mailing Address - Fax:
Practice Address - Street 1:112 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834-1622
Practice Address - Country:US
Practice Address - Phone:405-258-3040
Practice Address - Fax:405-240-5008
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1775101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health