Provider Demographics
NPI:1043966583
Name:WALLER, EVELYN (LMSW)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30777 NORTHWESTERN HWY STE 104
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2592
Mailing Address - Country:US
Mailing Address - Phone:313-300-0744
Mailing Address - Fax:
Practice Address - Street 1:30777 NORTHWESTERN HWY STE 104
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2592
Practice Address - Country:US
Practice Address - Phone:313-300-0744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010768811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical