Provider Demographics
NPI:1508356130
Name:LALLY, PAUL MICHAEL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:MICHAEL
Last Name:LALLY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7525 METROPOLITAN DR STE 306
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4404
Mailing Address - Country:US
Mailing Address - Phone:844-316-7979
Mailing Address - Fax:866-813-1235
Practice Address - Street 1:7525 METROPOLITAN DR STE 306
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4404
Practice Address - Country:US
Practice Address - Phone:844-316-7979
Practice Address - Fax:866-813-1235
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013485225100000X
TN11752225100000X
CAPT299985225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA299985OtherPT LICENSE