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General NPI Number Information
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NPI Number | 1659866556
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Entity Type | Individual
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Provider Name | CHARLES CUTEZ WALLER PSY.D.
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Gender | Male
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Dates
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Enumeration Date | 06/25/2018
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Last Update Date | 08/24/2023
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Provider Practice Location Address
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Address Line | 8221 WILLOW OAKS CORPORATE DR STE 4-425
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City | FAIRFAX
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State | VA
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Zip | 22031-4512
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Country | US
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Telephone | 703-289-7560
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Fax | 703-289-4612
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Provider Business Mailing Address
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Address Line | 5605 CYPRESS CREEK DR APT 203
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City | CHILLUM
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State | MD
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Zip | 20782-3511
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Country | US
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Telephone | 504-402-3601
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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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 | 0810008049
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License Number State | VA
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