Provider Demographics
NPI:1912530429
Name:WALLER, LINDSAY CONSTANCE (BCBA)
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:CONSTANCE
Last Name:WALLER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 W THOMAS ST STE C
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2744
Mailing Address - Country:US
Mailing Address - Phone:478-451-0557
Mailing Address - Fax:
Practice Address - Street 1:530 W THOMAS ST STE C
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2744
Practice Address - Country:US
Practice Address - Phone:478-451-0557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-20-40658103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst