Provider Demographics
NPI:1245249986
Name:WALLES, ERICA LYN (PHD)
Entity type:Individual
Prefix:DR
First Name:ERICA
Middle Name:LYN
Last Name:WALLES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:
Other - Last Name:SHERTZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:CREDENTIALS DEPT
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-1335
Practice Address - Country:US
Practice Address - Phone:570-271-6516
Practice Address - Fax:570-271-5814
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016174103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017660620001Medicaid
PASH106932Medicare PIN