Basic Information
| Provider Information | |||||||||
| NPI: | 1902888175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE-DIGARBO | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHD CAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1755 OREGON PIKE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176014272 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1755 OREGON PIKE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176014272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175815255 | ||||||||
| FaxNumber: | 7175815259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 10/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PS008309L | PA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 951513 | 01 | PA | BLUE SHIELD | OTHER |