Provider Demographics
NPI:1609314616
Name:LALLY, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LALLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 SPRINGBROOK DR.
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-5946
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4711 GOLF RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1224
Practice Address - Country:US
Practice Address - Phone:847-676-4327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst