Provider Demographics
NPI:1790375103
Name:WALLER, JOE MICHAEL (LPC)
Entity Type:Individual
Prefix:MR
First Name:JOE
Middle Name:MICHAEL
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 1:2323 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-7704
Mailing Address - Country:US
Mailing Address - Phone:903-535-7421
Mailing Address - Fax:903-535-7384
Practice Address - Street 1:703 W PATTEN ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:TX
Practice Address - Zip Code:75773-1541
Practice Address - Country:US
Practice Address - Phone:903-569-5409
Practice Address - Fax:900-353-5738
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX419100901Medicaid