Healthcare Provider Details

I. General information

NPI: 1831821842
Provider Name (Legal Business Name): CAITLYN WALLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 RAYBROOK ST SE
GRAND RAPIDS MI
49546-7717
US

IV. Provider business mailing address

1522 COLE AVE NE APT 2
GRAND RAPIDS MI
49505-5027
US

V. Phone/Fax

Practice location:
  • Phone: 616-202-4444
  • Fax:
Mailing address:
  • Phone: 989-390-2561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451022295
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: