Provider Demographics
NPI:1790404721
Name:DALLEY, MIRAN (LGPC)
Entity Type:Individual
Prefix:
First Name:MIRAN
Middle Name:
Last Name:DALLEY
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 BEACON HILL CT
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-5401
Mailing Address - Country:US
Mailing Address - Phone:240-805-8805
Mailing Address - Fax:
Practice Address - Street 1:849 QUINCE ORCHARD BLVD STE I
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-1684
Practice Address - Country:US
Practice Address - Phone:301-818-8182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704015005101YM0800X
MDLGP11834101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health