MEDICARE: RYAN CASEY WALLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	203628	TX

General Provider Information

NPI Number	:	1598468597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN CASEY WALLER

Provider Business Mailing Address
First Line	:	4514 COLE AVE STE 200
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75205-4153
Country	:	US
Telephone Number	:	817-586-8537
Fax Number	:

Provider Business Practice Location Address
First Line	:	4514 COLE AVE STE 200
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75205-4153
Country	:	US
Telephone Number	:	817-586-8537
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2023
Last Update Date	:	10/01/2025

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