Provider Demographics
NPI:1255436770
Name:RALLIS, MARIA (PHD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:
Last Name:RALLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 WEST 12TH
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505
Mailing Address - Country:US
Mailing Address - Phone:814-835-7043
Mailing Address - Fax:
Practice Address - Street 1:3800 WEST 12TH
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505
Practice Address - Country:US
Practice Address - Phone:814-835-7043
Practice Address - Fax:814-838-2925
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-008804-L103TC0700X
PAPS0088804L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA039974Medicare PIN