Provider Demographics
NPI:1144516519
Name:WALLER, HENERY JR (MSW)
Entity type:Individual
Prefix:MR
First Name:HENERY
Middle Name:
Last Name:WALLER
Suffix:JR
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18031 US HIGHWAY 18
Mailing Address - Street 2:SUITE F
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18031 US HIGHWAY 18
Practice Address - Street 2:SUITE F
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2152
Practice Address - Country:US
Practice Address - Phone:760-242-1300
Practice Address - Fax:760-242-1331
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA214131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical