Healthcare Provider Details

I. General information

NPI: 1629758404
Provider Name (Legal Business Name): ALISSA BLAKE WALRUTH LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2023
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SCHOOL DR
PENN YAN NY
14527-1081
US

IV. Provider business mailing address

601B W WASHINGTON ST
GENEVA NY
14456-2119
US

V. Phone/Fax

Practice location:
  • Phone: 315-924-6050
  • Fax:
Mailing address:
  • Phone: 315-787-8151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number013651
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number1578785221
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: