Provider Demographics
NPI:1023860202
Name:WALLER, MALIA (M ED, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:MALIA
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:M ED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7442 COBLENTZ AVE
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20187-9001
Mailing Address - Country:US
Mailing Address - Phone:703-623-5471
Mailing Address - Fax:
Practice Address - Street 1:7442 COBLENTZ AVE
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20187-9001
Practice Address - Country:US
Practice Address - Phone:703-623-5471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133003530103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst