Provider Demographics
NPI:1790404721
Name:DALLEY, MIRAN (LPC)
Entity type:Individual
Prefix:
First Name:MIRAN
Middle Name:
Last Name:DALLEY
Suffix:
Gender:
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 S SUMMIT AVE STE 100-A40
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2089
Mailing Address - Country:US
Mailing Address - Phone:301-818-8182
Mailing Address - Fax:
Practice Address - Street 1:12 S SUMMIT AVE STE 100-A6
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2089
Practice Address - Country:US
Practice Address - Phone:301-818-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704015005101YM0800X, 101YP2500X
MDLC14005101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health