Individual
STACEY WALLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PH.D.
Contact information
Practice address
1097 FLEDDERJOHN RD STE 3, CHARLESTON, WV 25314-4208
(304) 345-0880
(304) 345-1112
Mailing address
1097 FLEDDERJOHN RD STE 3, CHARLESTON, WV 25314-4208
(304) 345-0880
(304) 345-1112
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
891
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3810001772
—
WV
Enumeration date
02/10/2006
Last updated
06/04/2008
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