Provider Demographics
NPI:1730581349
Name:WALLER, STACEY (LSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-1410
Mailing Address - Country:US
Mailing Address - Phone:609-386-0650
Mailing Address - Fax:609-386-0652
Practice Address - Street 1:116 W BROAD ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON CITY
Practice Address - State:NJ
Practice Address - Zip Code:08016-1410
Practice Address - Country:US
Practice Address - Phone:609-386-0650
Practice Address - Fax:609-386-0652
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05147700104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker