Provider Demographics
NPI:1972602035
Name:WALLER, NANCY (LCSW)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1729
Mailing Address - Country:US
Mailing Address - Phone:405-809-4222
Mailing Address - Fax:405-364-5379
Practice Address - Street 1:3037 NW 63RD ST
Practice Address - Street 2:STE 104
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-3637
Practice Address - Country:US
Practice Address - Phone:405-524-3278
Practice Address - Fax:405-364-5379
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK$$$$$$$$$PMedicare PIN