Basic Information
| Provider Information | |||||||||
| NPI: | 1093783110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAAK | ||||||||
| FirstName: | IRENE | ||||||||
| MiddleName: | BURRER | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 PLEASANT VALLEY DR STE 210 | ||||||||
| Address2: | |||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780065683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302674575 | ||||||||
| FaxNumber: | 8302674575 | ||||||||
| Practice Location | |||||||||
| Address1: | 113 PLEASANT VALLEY DR STE 210 | ||||||||
| Address2: | |||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780065683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302674575 | ||||||||
| FaxNumber: | 8302674575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 16905 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1866824-03 | 05 | TX | MEDICAID |