Healthcare Provider Details

I. General information

NPI: 1972272961
Provider Name (Legal Business Name): JULIANNA ROSE WALLER MSW, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 W MAIN ST
SAINT CLAIRSVILLE OH
43950-1225
US

IV. Provider business mailing address

4697 HARRISON ST
BELLAIRE OH
43906-1338
US

V. Phone/Fax

Practice location:
  • Phone: 304-905-5501
  • Fax:
Mailing address:
  • Phone: 740-968-7006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberS.2308693
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: