Provider Demographics
NPI:1366190100
Name:WOLLACH, CLARIE-ANN HENRIQUES (PSYD)
Entity type:Individual
Prefix:DR
First Name:CLARIE-ANN
Middle Name:HENRIQUES
Last Name:WOLLACH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:CLARIE-ANN
Other - Middle Name:
Other - Last Name:HENRIQUES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:1167 W BALTIMORE PIKE # 181
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:233 E LANCASTER AVE STE 303
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-2321
Practice Address - Country:US
Practice Address - Phone:610-551-1819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS019450103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical