Provider Demographics
NPI:1790383511
Name:WALLER, LORRAINE EILEEN (MA)
Entity Type:Individual
Prefix:MS
First Name:LORRAINE
Middle Name:EILEEN
Last Name:WALLER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-5131
Mailing Address - Country:US
Mailing Address - Phone:847-360-1020
Mailing Address - Fax:
Practice Address - Street 1:2025 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5131
Practice Address - Country:US
Practice Address - Phone:847-360-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health