Provider Demographics
NPI:1407888621
Name:WALLER, LINDA KATHRYN (LICSW, BCD, DCSW)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:KATHRYN
Last Name:WALLER
Suffix:
Gender:F
Credentials:LICSW, BCD, DCSW
Other - Prefix:MS
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW,BCD,DCSW,LAC
Mailing Address - Street 1:300 13TH AVE W STE 1
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4875
Mailing Address - Country:US
Mailing Address - Phone:701-227-7508
Mailing Address - Fax:701-227-7575
Practice Address - Street 1:300 13TH AVE W STE 1
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4875
Practice Address - Country:US
Practice Address - Phone:701-227-7508
Practice Address - Fax:701-227-7575
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND18261041C0700X
ND1593101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54523Medicaid
ND12661OtherBC/BS PIN
R95361Medicare UPIN
ND12661OtherBC/BS PIN