Provider Demographics
NPI:1659306512
Name:LALL, MYRA (MA)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:LALL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 186
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:MA
Mailing Address - Zip Code:02726-0186
Mailing Address - Country:US
Mailing Address - Phone:508-558-9700
Mailing Address - Fax:508-676-0935
Practice Address - Street 1:1 WELBY RD
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02745-1137
Practice Address - Country:US
Practice Address - Phone:508-558-9700
Practice Address - Fax:508-676-0935
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2024-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA383103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0502715Medicaid
MA0502715Medicaid