Provider Demographics
NPI:1790183176
Name:RALL, SALLY JANE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:JANE
Last Name:RALL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3255 EDBY RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-2657
Mailing Address - Country:US
Mailing Address - Phone:571-236-6823
Mailing Address - Fax:
Practice Address - Street 1:3406 ADLER AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99703
Practice Address - Country:US
Practice Address - Phone:571-236-6823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-16
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK137972101YP2500X
IL178-000147101YP2500X
AL1543103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional