Provider Demographics
NPI:1588964795
Name:WALLER, JULIA J (LCSW)
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:J
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 1:367 ATHENS HWY STE 1800
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8293
Mailing Address - Country:US
Mailing Address - Phone:770-554-2999
Mailing Address - Fax:770-679-6390
Practice Address - Street 1:367 ATHENS HWY STE 1800
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-8293
Practice Address - Country:US
Practice Address - Phone:770-554-2999
Practice Address - Fax:770-679-6390
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW004942104100000X
GACSW0047291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker