Provider Demographics
NPI:1194041509
Name:WALLER, CHRISTINA CLAIR (LCSW)
Entity type:Individual
Prefix:MS
First Name:CHRISTINA
Middle Name:CLAIR
Last Name:WALLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2029 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6600
Mailing Address - Country:US
Mailing Address - Phone:910-798-6500
Mailing Address - Fax:910-341-4135
Practice Address - Street 1:2029 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6600
Practice Address - Country:US
Practice Address - Phone:910-798-6500
Practice Address - Fax:910-341-4135
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0072871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical