Provider Demographics
NPI:1740352764
Name:DALLALIO-CROTTY, LAURA J
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:DALLALIO-CROTTY
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 1:8930 GEORGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:OWENTON
Mailing Address - State:KY
Mailing Address - Zip Code:40359-8900
Mailing Address - Country:US
Mailing Address - Phone:502-290-0660
Mailing Address - Fax:
Practice Address - Street 1:8930 GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:OWENTON
Practice Address - State:KY
Practice Address - Zip Code:40359-8900
Practice Address - Country:US
Practice Address - Phone:502-797-6890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH-11777101YM0800X
KY1033-20101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKY 0087OtherLICENSE # LPCA