Provider Demographics
NPI:1396991493
Name:DALLY, TESS
Entity type:Individual
Prefix:
First Name:TESS
Middle Name:
Last Name:DALLY
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:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-0284
Mailing Address - Country:US
Mailing Address - Phone:907-235-6152
Mailing Address - Fax:907-235-6158
Practice Address - Street 1:3691 BEN WALTERS LN
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7750
Practice Address - Country:US
Practice Address - Phone:907-235-6152
Practice Address - Fax:907-235-6158
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101YA0400X
AK3791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)