Kevin Waller, LPCS, LCAS, CCS

Primary specialty

Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X

License

3145 Issued in NC

Practice address

363 Graphite Rd
Old Fort, NC 28762-9455

Phone

(828) 668-7590

NPI assigned

Jul 31, 2018

Last updated

Jul 31, 2018By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Suws of the Carolinas

  • Emotionally Disturbed Childrens' Residential Treatment Facility
  • Old Fort, NC
  • NPI 1740470798
  NPD (past)
• Suws of the Carolinas

  • Emotionally Disturbed Childrens' Residential Treatment Facility
  • Old Fort, NC
  • NPI 1992025860
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1532995200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1532995200000",
    "number": "1023596244",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "363 GRAPHITE RD",
            "city": "OLD FORT",
            "state": "NC",
            "postal_code": "287629455",
            "telephone_number": "828-668-7590"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "363 GRAPHITE RD",
            "city": "OLD FORT",
            "state": "NC",
            "postal_code": "287629455",
            "telephone_number": "828-668-7590"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLER",
        "first_name": "KEVIN",
        "credential": "LPCS, LCAS, CCS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2018-07-31",
        "last_updated": "2018-07-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "NC",
            "license": "20998",
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NC",
            "license": "S7822",
            "primary": false
        },
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "NC",
            "license": "3145",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• John Robert Summerour, RPH
• Suws of the Carolinas
• Suws of the Carolinas
• The McDowell Hospital Inc (Mission Community Medicine Old Fort)
• Jon Charles Tripp, L.P.C.
• Ware Family Medicine PLLC
• Brian Michael Ware, D.O.
• Wings of Flight Center for Change, PLLC

• Addiction (Substance Use Disorder) Counselor in Old Fort, NC
• Providers in Old Fort, NC by specialty
• Addiction (Substance Use Disorder) Counselor in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 31, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.