Provider Demographics
NPI:1407964067
Name:LALLY, RICHARD A (LPC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:A
Last Name:LALLY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 GOLDEN EAGLE COURT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409
Mailing Address - Country:US
Mailing Address - Phone:912-429-9026
Mailing Address - Fax:
Practice Address - Street 1:5425 GOLDEN EAGLE COURT
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409
Practice Address - Country:US
Practice Address - Phone:912-429-9026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003989101YP2500X
NC10112101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional