Healthcare Provider Details

I. General information

NPI: 1760980577
Provider Name (Legal Business Name): RYAN M. WALLACE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2018
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 MAIN ST
WINTERSVILLE OH
43953-4800
US

IV. Provider business mailing address

101 PEMBROKE CT
GREENSBURG PA
15601-6404
US

V. Phone/Fax

Practice location:
  • Phone: 724-396-1510
  • Fax: 724-972-4627
Mailing address:
  • Phone: 724-396-1510
  • Fax: 724-972-4627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2607590
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: