Provider Demographics
NPI:1326652702
Name:WALLER PSYCHOTHERAPY, LLC
Entity Type:Organization
Organization Name:WALLER PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:SR
Authorized Official - Credentials:EDD, LPC
Authorized Official - Phone:703-675-7378
Mailing Address - Street 1:11007 SWEET APPLE CT
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-7103
Mailing Address - Country:US
Mailing Address - Phone:703-675-7378
Mailing Address - Fax:
Practice Address - Street 1:11007 SWEET APPLE CT
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-7103
Practice Address - Country:US
Practice Address - Phone:703-675-7378
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-03
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health