Provider Demographics
NPI:1609580166
Name:WALLER, KURTASHA D
Entity Type:Individual
Prefix:
First Name:KURTASHA
Middle Name:D
Last Name:WALLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 NELSON CREEK LN
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-9816
Mailing Address - Country:US
Mailing Address - Phone:276-806-9615
Mailing Address - Fax:
Practice Address - Street 1:51 SHUMATE DR
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24078-1652
Practice Address - Country:US
Practice Address - Phone:276-806-9615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician