Provider Demographics
NPI:1417233073
Name:WALLER, KIMBERLY B (MA, LPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:B
Last Name:WALLER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 SUNNYBROOK RD
Mailing Address - Street 2:WAKE BROOK BUILDING
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1827
Mailing Address - Country:US
Mailing Address - Phone:919-747-0507
Mailing Address - Fax:919-747-0577
Practice Address - Street 1:107 SUNNYBROOK RD
Practice Address - Street 2:WAKE BROOK BUILDING
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1827
Practice Address - Country:US
Practice Address - Phone:919-747-0507
Practice Address - Fax:919-747-0577
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7498101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional