Provider Demographics
NPI:1508876582
Name:WALLER, SALLY ANN (PHD, LMHC)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:WALLER
Suffix:
Gender:F
Credentials:PHD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17321 EVANSTON AVE N
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-5235
Mailing Address - Country:US
Mailing Address - Phone:206-533-0776
Mailing Address - Fax:206-533-0776
Practice Address - Street 1:17321 EVANSTON AVE N
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-5235
Practice Address - Country:US
Practice Address - Phone:206-533-0776
Practice Address - Fax:206-533-0776
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00005716101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health