Provider Demographics
NPI:1023215282
Name:LALLY, ANGELLA BRICKNER (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANGELLA
Middle Name:BRICKNER
Last Name:LALLY
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S BRAINARD AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6107
Mailing Address - Country:US
Mailing Address - Phone:773-860-4826
Mailing Address - Fax:
Practice Address - Street 1:505 S BRAINARD AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-6107
Practice Address - Country:US
Practice Address - Phone:773-860-4826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146006925235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist