Provider Demographics
NPI:1770932840
Name:WALLER, MARY (MED, LPC, NCC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:MED, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10985 N HARRELLS FERRY RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8362
Mailing Address - Country:US
Mailing Address - Phone:225-485-7005
Mailing Address - Fax:
Practice Address - Street 1:10985 N HARRELLS FERRY RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8362
Practice Address - Country:US
Practice Address - Phone:225-485-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4584101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional