=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568485506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA WALLER PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 08/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 E 34TH ST APT 9G
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-4977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-689-1048
-----------------------------------------------------
Fax | 646-398-9367
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 E 34TH ST APT 9G
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-5231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-689-1048
-----------------------------------------------------
Fax | 646-398-9367
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | RPO117461
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------