Basic Information
| Provider Information | |||||||||
| NPI: | 1952030793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLS | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | ROGER | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 ELSINORE PL | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452021459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8335104357 | ||||||||
| FaxNumber: | 8664602997 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 FARADAY PLZ | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226034669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8335104357 | ||||||||
| FaxNumber: | 8664602997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2022 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 0704013133 | VA | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | 0701011585 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.