Liam Nikolas Jaxson Waller, LCSWA

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

P016334 Issued in NC

Practice address

895 State Farm Rd Ste 507-5
Boone, NC 28607-4917

Phone

(828) 338-3136

NPI assigned

Jun 28, 2021

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

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

• Evergreen Counseling and Wellness, PLLC

  • Professional Counselor
  • Boone, NC
  • NPI 1992369680
  NPD

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

{
    "created_epoch": "1624838400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1624838400000",
    "number": "1780254136",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "156 CHASE COLE LN",
            "city": "ZIONVILLE",
            "state": "NC",
            "postal_code": "286986002",
            "telephone_number": "336-981-6723"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "895 STATE FARM RD STE 507-5",
            "city": "BOONE",
            "state": "NC",
            "postal_code": "286074917",
            "telephone_number": "828-338-3136"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLER",
        "first_name": "LIAM",
        "middle_name": "NIKOLAS JAXSON",
        "name_prefix": "Mr.",
        "credential": "LCSWA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-06-28",
        "last_updated": "2021-06-28",
        "certification_date": "2021-06-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NC",
            "license": "P016334",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Wesley Joseph Waldrep, DMD
• Walgreen Co
• Walgreen Co
• Walgreen Co
• Bonnie Lucile Walker, DC, L AC
• Sherry Ayscue Walsh, LCSWA
• Emma Shepherd Walters
• Judith Annette Ward, LCSW
• Kathryn Warner, LCSWA
• Blaire Elizabeth Warren, DDS

• Clinical Social Worker in Boone, NC
• Providers in Boone, NC by specialty
• Clinical Social Worker in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 28, 2021; 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.