Provider Demographics
NPI:1760543508
Name:WALLER, ROBERT RAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:RAY
Last Name:WALLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8304 NW 113TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-2136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 S BROADWAY
Practice Address - Street 2:BUILDING 200
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-4038
Practice Address - Country:US
Practice Address - Phone:405-721-5145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK772103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical