Provider Demographics
NPI:1598200370
Name:WALLER, RONALD (RN)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:WALLER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 FORT DR STE 207
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2425
Mailing Address - Country:US
Mailing Address - Phone:703-659-1292
Mailing Address - Fax:703-659-9607
Practice Address - Street 1:5900 FORT DR STE 207
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2425
Practice Address - Country:US
Practice Address - Phone:703-659-1292
Practice Address - Fax:703-659-9607
Is Sole Proprietor?:No
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001152470101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health