Provider Demographics
NPI:1588198378
Name:WALLER, MELISSA MARIE (CDPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:WALLER
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 E CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-3403
Mailing Address - Country:US
Mailing Address - Phone:360-681-8463
Mailing Address - Fax:360-683-8465
Practice Address - Street 1:390 E CEDAR ST
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3403
Practice Address - Country:US
Practice Address - Phone:360-681-8463
Practice Address - Fax:360-683-8465
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO 60669921101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)