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General NPI Number Information
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NPI Number | 1629758404
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Entity Type | Individual
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Provider Name | ALISSA BLAKE WALRUTH LMHC
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Gender | Female
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Dates
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Enumeration Date | 07/18/2023
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Last Update Date | 07/18/2023
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Provider Practice Location Address
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Address Line | 280 PRINCETON AVENUE EXT
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City | CORNING
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State | NY
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Zip | 14830-1524
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Country | US
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Telephone | 607-962-3146
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Fax |
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Provider Business Mailing Address
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Address Line | 14471 W LAKE RD
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City | HAMMONDSPORT
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State | NY
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Zip | 14840-8549
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Country | US
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Telephone | 607-684-4594
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 013651
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 101YS0200X
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Taxonomy Name | School Counselor
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License Number | 1578785221
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License Number State | NY
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