Provider Demographics
NPI:1629758404
Name:WALRUTH, ALISSA BLAKE (LMHC)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:BLAKE
Last Name:WALRUTH
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14471 W LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HAMMONDSPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14840-8549
Mailing Address - Country:US
Mailing Address - Phone:607-684-4594
Mailing Address - Fax:
Practice Address - Street 1:280 PRINCETON AVENUE EXT
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-1524
Practice Address - Country:US
Practice Address - Phone:607-962-3146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013651101YM0800X
NY1578785221101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool