MEDICARE: STACEY 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	104100000X	Social Worker	44SL05147700	NJ

General Provider Information

NPI Number	:	1730581349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY WALLER LSW

Provider Business Mailing Address
First Line	:	116 W BROAD ST
Second Line	:
City	:	BURLINGTON CITY
State	:	NJ
Zip	:	08016-1410
Country	:	US
Telephone Number	:	609-386-0650
Fax Number	:	609-386-0652

Provider Business Practice Location Address
First Line	:	116 W BROAD ST
Second Line	:
City	:	BURLINGTON CITY
State	:	NJ
Zip	:	08016-1410
Country	:	US
Telephone Number	:	609-386-0650
Fax Number	:	609-386-0652

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

Provider Enumeration Date	:	09/25/2014
Last Update Date	:	09/25/2014

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