Provider Demographics
NPI:1033258769
Name:WALLER, DERICA (LCSW)
Entity Type:Individual
Prefix:
First Name:DERICA
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8089 S LINCOLN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80122-2700
Mailing Address - Country:US
Mailing Address - Phone:303-915-5567
Mailing Address - Fax:
Practice Address - Street 1:8089 S LINCOLN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80122-2700
Practice Address - Country:US
Practice Address - Phone:303-915-5567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical