Provider Demographics
NPI:1154811438
Name:WALLER, GLORIA JEAN (LPC)
Entity type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:JEAN
Last Name:WALLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:GLORIA
Other - Middle Name:JAMES
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCDC
Mailing Address - Street 1:4365 LOMA ALEGRE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79934-3766
Mailing Address - Country:US
Mailing Address - Phone:915-328-2595
Mailing Address - Fax:915-639-9532
Practice Address - Street 1:1900 DENVER AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3008
Practice Address - Country:US
Practice Address - Phone:915-544-2349
Practice Address - Fax:915-639-9532
Is Sole Proprietor?:No
Enumeration Date:2018-05-13
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12881101YA0400X
TX73537101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)