Provider Demographics
NPI:1366295933
Name:WALLER, MARIAH
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3463 FORT AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-3828
Mailing Address - Country:US
Mailing Address - Phone:803-348-2485
Mailing Address - Fax:
Practice Address - Street 1:20276A TIMBERLAKE RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-7214
Practice Address - Country:US
Practice Address - Phone:434-319-5528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health