MEDICARE: FIONA CHRISTINE WALLER LCSW

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	104100000X	Social Worker	2020013516	MO
2	1041C0700X	Clinical Social Worker	2022029180	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2020013516	OTHER	MO	SOCIAL WORK LICENSE
2	2022029180	OTHER	MO	LCSW

General Provider Information

NPI Number	:	1710552203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FIONA CHRISTINE WALLER LCSW

Provider Business Mailing Address
First Line	:	145 MORRIS LN UNIT 108
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-1389
Country	:	US
Telephone Number	:	630-596-7359
Fax Number	:

Provider Business Practice Location Address
First Line	:	145 MORRIS LN UNIT 108
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-1389
Country	:	US
Telephone Number	:	630-596-7359
Fax Number	:

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

Provider Enumeration Date	:	05/26/2021
Last Update Date	:	01/23/2024

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