Healthcare Provider Details

I. General information

NPI: 1447647078
Provider Name (Legal Business Name): KEVIN LALLY LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W CENTRE ST
MAHANOY CITY PA
17948-2670
US

IV. Provider business mailing address

1 W CENTRE ST
MAHANOY CITY PA
17948-2670
US

V. Phone/Fax

Practice location:
  • Phone: 570-773-3470
  • Fax:
Mailing address:
  • Phone: 570-773-3470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW018621
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: