| Doctor Name: | MR. ELMER WALLER |
| NPI Number: | 1013152800 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 436 5th Street Ted Stevens Way Kotzebue, AK - 99752 |
| Business Phone Number: | 9074427640 |
| Business Fax Number: | 9074427822 |
| Mailing Address: | 436 5th Street Ted Stevens Way, KOTZEBUE |
| State: | AK |
| Postal Code: | 99752 |
| Phone Number: | 9074427640 |
| Fax Number: | 9074427822 |
| NPI Enumeration Date: | 12/08/2008 |
| NPI Last Update Date: | 12/08/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |