Provider Demographics
NPI:1114990900
Name:WALLER, STACEY (PHD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1097 FLEDDERJOHN RD STE 3
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-4208
Mailing Address - Country:US
Mailing Address - Phone:304-345-0880
Mailing Address - Fax:304-345-1112
Practice Address - Street 1:1097 FLEDDERJOHN RD STE 3
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-4208
Practice Address - Country:US
Practice Address - Phone:304-345-0880
Practice Address - Fax:304-345-1112
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV891103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001772Medicaid
WVWACP30781Medicare ID - Type Unspecified
WV3810001772Medicaid