Candice Waller, LPC-MHSP

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

LPC-19614 Issued in AZ

Practice address

5055 E Broadway Blvd Ste C104
Tucson, AZ 85711-3641

Phone

(520) 623-9833

Fax

(520) 923-9083

NPI assigned

Jan 18, 2019

Last updated

Jun 13, 2022By the provider in NPPES

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

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

{
    "created_epoch": "1547769600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1655078400000",
    "number": "1588138911",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7670 N STAR GRASS DR",
            "city": "TUCSON",
            "state": "AZ",
            "postal_code": "857414952",
            "telephone_number": "678-925-6598"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5055 E BROADWAY BLVD STE C104",
            "city": "TUCSON",
            "state": "AZ",
            "postal_code": "857113641",
            "telephone_number": "520-623-9833",
            "fax_number": "520-923-9083"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2856 Bridle Creek Dr SW",
            "address_purpose": "LOCATION",
            "city": "Conyers",
            "state": "GA",
            "postal_code": "300945677",
            "country_code": "US",
            "telephone_number": "678-925-6598",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "7670 N Star Grass Dr",
            "address_purpose": "LOCATION",
            "city": "Tucson",
            "state": "AZ",
            "postal_code": "857414952",
            "country_code": "US",
            "telephone_number": "678-925-6598",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLER",
        "first_name": "CANDICE",
        "credential": "LPC-MHSP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2019-01-18",
        "last_updated": "2022-06-13",
        "certification_date": "2022-06-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "TN",
            "license": "LPC0000004067",
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "AZ",
            "license": "LPC-19614",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE",
            "identifier": "LPC-19614",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Shawnesha Wallace, BCBA, LBA
• Stephanie Wallace, PA-C
• Steven B Wallach, D.O.
• Keira Wallenborn, MA, CCC-SLP
• Kaylee Wallentine
• Kurt David Wallin, D.M.D.
• Salley A Wallin, LCSW, MSW
• Corinne Elizabeth Wallis, PT, DPT
• Helena Wallis, LMT
• Mara Wallisch, PT, DPT

• Professional Counselor in Tucson, AZ
• Providers in Tucson, AZ by specialty
• Professional Counselor in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 13, 2022; 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.