Provider Demographics
NPI:1497320089
Name:QUALLS, TANYA M (LPC)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:M
Last Name:QUALLS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KAI
Other - Middle Name:
Other - Last Name:QUALLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:113 W WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-4099
Mailing Address - Country:US
Mailing Address - Phone:610-687-6415
Mailing Address - Fax:
Practice Address - Street 1:113 W WAYNE AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-4099
Practice Address - Country:US
Practice Address - Phone:610-687-6415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YP2500X
PAPC012607101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional