Provider Demographics
NPI:1013064328
Name:WALLER, BYRON (PHD)
Entity Type:Individual
Prefix:DR
First Name:BYRON
Middle Name:
Last Name:WALLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:BYRON
Other - Middle Name:
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:12653 S POTOMAC DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-9620
Mailing Address - Country:US
Mailing Address - Phone:312-218-8483
Mailing Address - Fax:
Practice Address - Street 1:12653 S POTOMAC DR
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-9620
Practice Address - Country:US
Practice Address - Phone:312-218-8483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005749101YM0800X, 101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor