1285725689 NPI number — MARTIN TERRANCE LALLY PHD PSYCHOLOGIST

Table of content: MARTIN TERRANCE LALLY PHD PSYCHOLOGIST (NPI 1285725689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285725689 NPI number — MARTIN TERRANCE LALLY PHD PSYCHOLOGIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LALLY
Provider First Name:
MARTIN
Provider Middle Name:
TERRANCE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD PSYCHOLOGIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285725689
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14900
Provider Second Line Business Mailing Address:
STATE OF OREGON IRS UNIT
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97309-5016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-945-9840
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1121 NE 2ND
Provider Second Line Business Practice Location Address:
OREGON STATE HOSPITAL
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-731-8656
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  712 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com