Provider Demographics
NPI:1508544883
Name:WALLACE, MARA (LPC)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:WALLACE
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 1:95 ENTERPRISE ST STE 104
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:PA
Mailing Address - Zip Code:15037-2070
Mailing Address - Country:US
Mailing Address - Phone:412-754-1100
Mailing Address - Fax:
Practice Address - Street 1:95 ENTERPRISE ST STE 104
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:PA
Practice Address - Zip Code:15037-2070
Practice Address - Country:US
Practice Address - Phone:412-754-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC015793101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional