Provider Demographics
NPI:1598246043
Name:LALLY, NICOLE (LCSW TCADC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:LALLY
Suffix:
Gender:F
Credentials:LCSW TCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:961 BEASLEY ST STE 170
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-4120
Mailing Address - Country:US
Mailing Address - Phone:859-382-7328
Mailing Address - Fax:859-286-6448
Practice Address - Street 1:961 BEASLEY ST STE 170
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-4120
Practice Address - Country:US
Practice Address - Phone:859-382-7328
Practice Address - Fax:859-286-6448
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY70161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical