Provider Demographics
NPI:1710552203
Name:WALLER, FIONA CHRISTINE (LCSW)
Entity Type:Individual
Prefix:
First Name:FIONA
Middle Name:CHRISTINE
Last Name:WALLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 MORRIS LN UNIT 108
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1389
Mailing Address - Country:US
Mailing Address - Phone:630-596-7359
Mailing Address - Fax:
Practice Address - Street 1:145 MORRIS LN UNIT 108
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1389
Practice Address - Country:US
Practice Address - Phone:630-596-7359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020013516104100000X
MO20220291801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2020013516OtherSOCIAL WORK LICENSE
MO2022029180OtherLCSW