=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801322995
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERYKA WALLER LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2017
-----------------------------------------------------
Last Update Date | 05/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 S STATE ST 3RD FLOOR
-----------------------------------------------------
City | NEWTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18940-1963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-550-6109
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1313 W. WYNNEWOOD ROAD
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-504-5135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | SW132899
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------