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General NPI Number Information
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NPI Number | 1174014625
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Entity Type | Individual
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Provider Name | ROBERT SCOTT WALLER PSYD
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Gender | Male
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Dates
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Enumeration Date | 05/21/2018
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Last Update Date | 07/31/2019
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Provider Practice Location Address
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Address Line | 1276 N CLYBOURN AVE
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City | CHICAGO
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State | IL
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Zip | 60610
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Country | US
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Telephone | 312-337-1073
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Fax |
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Provider Business Mailing Address
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Address Line | 1441 W ELMDALE AVE APT 1S
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City | CHICAGO
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State | IL
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Zip | 60660-2405
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Country | US
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Telephone | 239-248-7437
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number | 071009689
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071009689
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License Number State | IL
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