Provider Demographics
NPI:1730306630
Name:WALLER, JOHN CHRISTIAN (LPC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:CHRISTIAN
Last Name:WALLER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 LATROBE DR STE 340
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4823
Mailing Address - Country:US
Mailing Address - Phone:704-364-3989
Mailing Address - Fax:
Practice Address - Street 1:3705 LATROBE DR STE 340
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211
Practice Address - Country:US
Practice Address - Phone:704-364-3989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5049101Y00000X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1730306630Medicaid