Provider Demographics
NPI:1346783321
Name:WALLER, CARLEEN
Entity Type:Individual
Prefix:
First Name:CARLEEN
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:896 ROBIN RANCH RD
Mailing Address - Street 2:
Mailing Address - City:LOCKHART
Mailing Address - State:TX
Mailing Address - Zip Code:78644-4578
Mailing Address - Country:US
Mailing Address - Phone:512-376-2101
Mailing Address - Fax:512-432-1677
Practice Address - Street 1:896 ROBIN RANCH RD
Practice Address - Street 2:
Practice Address - City:LOCKHART
Practice Address - State:TX
Practice Address - Zip Code:78644-4578
Practice Address - Country:US
Practice Address - Phone:512-376-2101
Practice Address - Fax:512-432-1677
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68992101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional