Provider Demographics
NPI:1497270466
Name:WALLER, SHERRIE THANG (LMSW)
Entity Type:Individual
Prefix:
First Name:SHERRIE
Middle Name:THANG
Last Name:WALLER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7312 35TH AVE APT B24
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-4205
Mailing Address - Country:US
Mailing Address - Phone:774-253-0862
Mailing Address - Fax:
Practice Address - Street 1:244 5TH AVE STE 9F
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-7604
Practice Address - Country:US
Practice Address - Phone:347-788-0820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093824104100000X
NY0919621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty