Provider Demographics
NPI:1174492532
Name:WALLER, WILLIAM W (CPH, MHFA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:W
Last Name:WALLER
Suffix:
Gender:M
Credentials:CPH, MHFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14540 ROSHOLT LOOP
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-2000
Mailing Address - Country:US
Mailing Address - Phone:501-231-8132
Mailing Address - Fax:
Practice Address - Street 1:806 S TEJON ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-4149
Practice Address - Country:US
Practice Address - Phone:501-231-8132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-03
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSTUDENT2026101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)