Provider Demographics
NPI:1629253521
Name:WALLER, ERIKA MCGRAW (PHD)
Entity Type:Individual
Prefix:DR
First Name:ERIKA
Middle Name:MCGRAW
Last Name:WALLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:ERIKA
Other - Middle Name:MCGRAW
Other - Last Name:LOCKERD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:211 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65211-0001
Mailing Address - Country:US
Mailing Address - Phone:573-882-4677
Mailing Address - Fax:573-882-4583
Practice Address - Street 1:211 S 8TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65211-0001
Practice Address - Country:US
Practice Address - Phone:573-882-4677
Practice Address - Fax:573-882-4583
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006034105103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490085577Medicaid