Provider Demographics
NPI:1083934574
Name:LALLY, VIVIANE PRODONOFF (M A)
Entity Type:Individual
Prefix:MRS
First Name:VIVIANE
Middle Name:PRODONOFF
Last Name:LALLY
Suffix:
Gender:F
Credentials:M A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 MAIN ST
Mailing Address - Street 2:SUITE 383
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1604
Mailing Address - Country:US
Mailing Address - Phone:774-245-7170
Mailing Address - Fax:
Practice Address - Street 1:340 MAIN ST
Practice Address - Street 2:SUITE 383
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1604
Practice Address - Country:US
Practice Address - Phone:774-245-7170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health