MEDICARE: STACEY WALLER PH.D.

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	103TC0700X	Clinical Psychologist	891	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114990900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY WALLER PH.D.

Provider Business Mailing Address
First Line	:	1097 FLEDDERJOHN RD STE 3
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25314-4208
Country	:	US
Telephone Number	:	304-345-0880
Fax Number	:	304-345-1112

Provider Business Practice Location Address
First Line	:	1097 FLEDDERJOHN RD STE 3
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25314-4208
Country	:	US
Telephone Number	:	304-345-0880
Fax Number	:	304-345-1112

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

Provider Enumeration Date	:	02/10/2006
Last Update Date	:	06/04/2008

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