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General NPI Number Information
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NPI Number | 1790375103
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Entity Type | Individual
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Provider Name | JOE MICHAEL WALLER LPC
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Gender | Male
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Dates
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Enumeration Date | 01/20/2021
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Last Update Date | 08/15/2022
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Provider Practice Location Address
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Address Line | 703 W PATTEN ST
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City | MINEOLA
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State | TX
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Zip | 75773-1541
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Country | US
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Telephone | 903-569-5409
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Fax | 900-353-5738
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Provider Business Mailing Address
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Address Line | 2323 W FRONT ST
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City | TYLER
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State | TX
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Zip | 75702-7704
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Country | US
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Telephone | 903-535-7421
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Fax | 903-535-7384
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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 | 101YP2500X
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Taxonomy Name | Professional 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 | 101YS0200X
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Taxonomy Name | School Counselor
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License Number |
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License Number State |
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