Provider Demographics
NPI:1154042596
Name:WALLY, MARYANNE (LPC)
Entity type:Individual
Prefix:MS
First Name:MARYANNE
Middle Name:
Last Name:WALLY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:ETNA
Mailing Address - State:PA
Mailing Address - Zip Code:15223-1841
Mailing Address - Country:US
Mailing Address - Phone:412-480-6854
Mailing Address - Fax:
Practice Address - Street 1:43 GRANT AVE
Practice Address - Street 2:
Practice Address - City:ETNA
Practice Address - State:PA
Practice Address - Zip Code:15223-1841
Practice Address - Country:US
Practice Address - Phone:412-480-6854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC014602101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional