Provider Demographics
NPI:1326142969
Name:WALLER, JANICE LEE (MED, CMHT)
Entity Type:Individual
Prefix:MRS
First Name:JANICE
Middle Name:LEE
Last Name:WALLER
Suffix:
Gender:F
Credentials:MED, CMHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 COUNTY ROAD 311
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-8533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:339 LEGION LN
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-8978
Practice Address - Country:US
Practice Address - Phone:662-509-9300
Practice Address - Fax:662-509-6698
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health