Provider Demographics
NPI:1710590146
Name:WALLER, AMANDA (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 SOUTH STREET PO BOX 1111
Mailing Address - Street 2:
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-4111
Mailing Address - Country:US
Mailing Address - Phone:908-310-7788
Mailing Address - Fax:
Practice Address - Street 1:154 WAYPOINT DR
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-2184
Practice Address - Country:US
Practice Address - Phone:908-310-7788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00637200101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional