Provider Demographics
NPI:1346490364
Name:WALLER, CHARLOTTE (LMHC)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MULBERRY STREET
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1230
Mailing Address - Country:US
Mailing Address - Phone:812-423-7791
Mailing Address - Fax:812-422-7558
Practice Address - Street 1:4001 JOHN STREET
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0247
Practice Address - Country:US
Practice Address - Phone:812-473-3144
Practice Address - Fax:812-422-7558
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000523A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100240880Medicaid