Provider Demographics
NPI:1942459102
Name:WALLY, LISA ANN (MS NCC CAC-DP LPC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:WALLY
Suffix:
Gender:F
Credentials:MS NCC CAC-DP LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 53
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-0053
Mailing Address - Country:US
Mailing Address - Phone:724-366-0153
Mailing Address - Fax:
Practice Address - Street 1:2 W MAIN ST
Practice Address - Street 2:SUITE 319
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-3408
Practice Address - Country:US
Practice Address - Phone:724-366-0153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-12
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005100101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional