Provider Demographics
NPI:1437842754
Name:WALLER, ALEXIS G (MS, MDIV, THD, LCPCC)
Entity Type:Individual
Prefix:DR
First Name:ALEXIS
Middle Name:G
Last Name:WALLER
Suffix:
Gender:F
Credentials:MS, MDIV, THD, LCPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 FEDERAL ST STE F
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-1508
Mailing Address - Country:US
Mailing Address - Phone:757-406-1831
Mailing Address - Fax:
Practice Address - Street 1:6 FEDERAL ST STE F
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-1508
Practice Address - Country:US
Practice Address - Phone:207-200-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL7023101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health