Individual
GARY WALLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LCSW
Contact information
Practice address
417 W CANAL ST, PICAYUNE, MS 39466-3951
(601) 749-9477
(769) 242-0030
Mailing address
417 W CANAL ST, PICAYUNE, MS 39466-3951
(601) 749-9477
(601) 749-0605
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
C11878
MS
104100000X
Social Worker
Primary
M9951
MS
1041C0700X
Clinical Social Worker
Primary
C11878
MS
Other
Enumeration date
09/15/2021
Last updated
06/22/2026
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