Healthcare Provider Details

I. General information

NPI: 1275567836
Provider Name (Legal Business Name): DAVID LALLY M.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 NORTH MAIN STREET
DAYVILLE CT
06241
US

IV. Provider business mailing address

3 MATHERS XING
SIMSBURY CT
06070-2479
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-2261
  • Fax:
Mailing address:
  • Phone: 860-456-2261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: