Provider Demographics
NPI:1215491386
Name:LALLY, AMANDA (LICSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:LALLY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 H ST SW APT 1228
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20024-0457
Mailing Address - Country:US
Mailing Address - Phone:225-249-9594
Mailing Address - Fax:
Practice Address - Street 1:1405 BRENTWOOD PKWY NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-2220
Practice Address - Country:US
Practice Address - Phone:225-249-9594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC2000032601041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool