MEDICARE: CANDICE WALLER LPC-MHSP

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	LPC0000004067	TN
2	101YP2500X	Professional Counselor	LPC-19614	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LPC-19614	OTHER	AZ	LICENSE

General Provider Information

NPI Number	:	1588138911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CANDICE WALLER LPC-MHSP

Provider Business Mailing Address
First Line	:	7670 N STAR GRASS DR
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85741-4952
Country	:	US
Telephone Number	:	678-925-6598
Fax Number	:

Provider Business Practice Location Address
First Line	:	5055 E BROADWAY BLVD STE C104
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85711-3641
Country	:	US
Telephone Number	:	520-623-9833
Fax Number	:	520-923-9083

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

Provider Enumeration Date	:	01/18/2019
Last Update Date	:	06/13/2022

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