Provider Demographics
NPI:1205545274
Name:WALLER, KIA M (CDCA)
Entity type:Individual
Prefix:
First Name:KIA
Middle Name:M
Last Name:WALLER
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:KIA
Other - Middle Name:M
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:725 BOARDMAN CANFIELD RD STE C4
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4367
Mailing Address - Country:US
Mailing Address - Phone:855-292-9778
Mailing Address - Fax:855-292-9778
Practice Address - Street 1:725 BOARDMAN CANFIELD RD STE C4
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-4367
Practice Address - Country:US
Practice Address - Phone:855-292-9778
Practice Address - Fax:855-292-9778
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.182720101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)