Provider Demographics
NPI:1285725689
Name:LALLY, MARTIN TERRANCE (PHD PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:TERRANCE
Last Name:LALLY
Suffix:
Gender:M
Credentials:PHD PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14900
Mailing Address - Street 2:STATE OF OREGON IRS UNIT
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-5016
Mailing Address - Country:US
Mailing Address - Phone:503-945-9840
Mailing Address - Fax:
Practice Address - Street 1:1121 NE 2ND
Practice Address - Street 2:OREGON STATE HOSPITAL
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-731-8656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR712103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R98647Medicare UPIN
115467Medicare ID - Type Unspecified