Provider Demographics
NPI:1477531424
Name:LALLY, JOAN W (LICSW)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:W
Last Name:LALLY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 WAYZATA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-2031
Mailing Address - Country:US
Mailing Address - Phone:952-270-4040
Mailing Address - Fax:952-546-1308
Practice Address - Street 1:11900 WAYZATA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2031
Practice Address - Country:US
Practice Address - Phone:952-270-4040
Practice Address - Fax:952-546-1308
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN166071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical