Individual
MARY ELIZABETH WALLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PHD
Contact information
Practice address
3619 PARK EAST DR, SUITE 313, BEACHWOOD, OH 44122-4330
(216) 591-0500
(216) 591-0550
Mailing address
3619 PARK EAST DR, SUITE 313, BEACHWOOD, OH 44122-4330
(216) 591-0500
(216) 591-0550
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
4312
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000137843
ANTHEM
OH
05
—
0857532
—
OH
01
—
244396000
MAGELLAN
OH
01
—
6100369
EVERCARE
OH
01
—
680009403
RAILROAD MEDICARE
OH
Enumeration date
10/18/2006
Last updated
07/08/2007
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