Provider Demographics
NPI:1952071631
Name:WALLER, CATHERINE (LCSW)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 COOPER RD STE D
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-2836
Mailing Address - Country:US
Mailing Address - Phone:601-749-9477
Mailing Address - Fax:601-749-0605
Practice Address - Street 1:1839 COOPER RD STE D
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-2836
Practice Address - Country:US
Practice Address - Phone:601-749-9477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC113191041C0700X
MSM99661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical