Provider Demographics
NPI:1508682469
Name:LALLY, GILIAN VIRGINIA
Entity type:Individual
Prefix:
First Name:GILIAN
Middle Name:VIRGINIA
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 1:8311 ARDLEIGH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-3415
Mailing Address - Country:US
Mailing Address - Phone:215-528-9172
Mailing Address - Fax:
Practice Address - Street 1:8311 ARDLEIGH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-3415
Practice Address - Country:US
Practice Address - Phone:215-528-9172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH005943103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst