Provider Demographics
NPI:1902888175
Name:WALLACE-DIGARBO, ANNE (PHD CAC)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:WALLACE-DIGARBO
Suffix:
Gender:F
Credentials:PHD CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 OREGON PIKE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-4272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1755 OREGON PIKE
Practice Address - Street 2:SUITE 200
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4272
Practice Address - Country:US
Practice Address - Phone:717-581-5255
Practice Address - Fax:717-581-5259
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008309L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA951513OtherBLUE SHIELD
PA951513OtherBLUE SHIELD
PAS42982Medicare UPIN