Provider Demographics
NPI:1922384932
Name:WALLER, BRIANNA (MS)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BARNETT AVE APT B
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-5099
Mailing Address - Country:US
Mailing Address - Phone:618-435-7893
Mailing Address - Fax:
Practice Address - Street 1:1307 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1139
Practice Address - Country:US
Practice Address - Phone:618-997-5336
Practice Address - Fax:618-993-2969
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor