Healthcare Provider Details

I. General information

NPI: 1780509265
Provider Name (Legal Business Name): SARAH WALLER
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 KIT CARSON RD
TAOS NM
87571-6407
US

IV. Provider business mailing address

332 KIT CARSON RD
TAOS NM
87571-6407
US

V. Phone/Fax

Practice location:
  • Phone: 832-516-1423
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: