Healthcare Provider Details

I. General information

NPI: 1114838273
Provider Name (Legal Business Name): LAURA BETH WALLER NBCHWC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1042 NEUHAVEN DR
ANTIOCH IL
60002-7290
US

IV. Provider business mailing address

1042 NEUHAVEN DR
ANTIOCH IL
60002-7290
US

V. Phone/Fax

Practice location:
  • Phone: 847-406-0548
  • Fax:
Mailing address:
  • Phone: 847-406-0548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: