Provider Demographics
NPI:1598220667
Name:NALLY, ALEXANDRA (CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:ALEXANDRA
Middle Name:
Last Name:NALLY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 MANTON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-4829
Mailing Address - Country:US
Mailing Address - Phone:267-481-2501
Mailing Address - Fax:
Practice Address - Street 1:636 MANTON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-4829
Practice Address - Country:US
Practice Address - Phone:267-481-2501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL014214235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14196124OtherAMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION LICENSE