Provider Demographics
NPI:1023596244
Name:WALLER, KEVIN (LPCS, LCAS, CCS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WALLER
Suffix:
Gender:M
Credentials:LPCS, LCAS, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 GRAPHITE RD
Mailing Address - Street 2:
Mailing Address - City:OLD FORT
Mailing Address - State:NC
Mailing Address - Zip Code:28762-9455
Mailing Address - Country:US
Mailing Address - Phone:828-668-7590
Mailing Address - Fax:
Practice Address - Street 1:363 GRAPHITE RD
Practice Address - Street 2:
Practice Address - City:OLD FORT
Practice Address - State:NC
Practice Address - Zip Code:28762-9455
Practice Address - Country:US
Practice Address - Phone:828-668-7590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20998101YA0400X
NCS7822101YM0800X
NC3145101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health