Provider Demographics
NPI:1548835390
Name:WALLER, LOISE KING (PHD)
Entity type:Individual
Prefix:DR
First Name:LOISE
Middle Name:KING
Last Name:WALLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4330 BULL CREEK RD APT 2416
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-5954
Mailing Address - Country:US
Mailing Address - Phone:512-797-4544
Mailing Address - Fax:
Practice Address - Street 1:1306 W LYNN ST RM 8
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-3956
Practice Address - Country:US
Practice Address - Phone:512-469-9447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38226103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical