Provider Demographics
NPI:1386219186
Name:WALLER-BOULET, LANEISHA S (PHD)
Entity Type:Individual
Prefix:DR
First Name:LANEISHA
Middle Name:S
Last Name:WALLER-BOULET
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 1:616 E BLOOMINGTON ST
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52245-2600
Mailing Address - Country:US
Mailing Address - Phone:319-337-6998
Mailing Address - Fax:
Practice Address - Street 1:616 E BLOOMINGTON ST
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-2600
Practice Address - Country:US
Practice Address - Phone:319-337-6998
Practice Address - Fax:319-354-1679
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling