MEDICARE: MR. DONNIE M. WALLER LSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	1775	OK

General Provider Information

NPI Number	:	1013020957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DONNIE M. WALLER LSW

Provider Business Mailing Address
First Line	:	RR 2 BOX 220B
Second Line	:
City	:	MEEKER
State	:	OK
Zip	:	74855-9305
Country	:	US
Telephone Number	:	405-214-9667
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 MCKINLEY AVE
Second Line	:
City	:	CHANDLER
State	:	OK
Zip	:	74834-1622
Country	:	US
Telephone Number	:	405-258-3040
Fax Number	:	405-240-5008

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	07/08/2007

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