Provider Demographics
NPI:1700956976
Name:NIEMELA-WALLER, KIRSI (PHD)
Entity Type:Individual
Prefix:
First Name:KIRSI
Middle Name:
Last Name:NIEMELA-WALLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 N BOWEN RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-2826
Mailing Address - Country:US
Mailing Address - Phone:817-543-3704
Mailing Address - Fax:817-543-3705
Practice Address - Street 1:1006 N BOWEN RD
Practice Address - Street 2:SUITE 124
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2826
Practice Address - Country:US
Practice Address - Phone:817-543-3704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30882103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041071403Medicaid
TX00445PMedicare UPIN