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General NPI Number Information
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NPI Number | 1790331270
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Entity Type | Individual
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Provider Name | JON WALLER LMHC
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Gender | Male
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Dates
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Enumeration Date | 08/12/2019
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Last Update Date | 08/12/2019
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Provider Practice Location Address
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Address Line | 4800 W COMMERCIAL BLVD
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City | TAMARAC
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State | FL
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Zip | 33319-2879
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Country | US
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Telephone | 954-300-3244
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Fax |
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Provider Business Mailing Address
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Address Line | 925 INTRACOASTAL DR APT 8
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City | FORT LAUDERDALE
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State | FL
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Zip | 33304-3688
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Country | US
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Telephone | 352-246-4027
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number | MH12508
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License Number State | FL
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