Provider Demographics
NPI:1427697234
Name:LALLY, DAWN (LMT, CLT)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:LALLY
Suffix:
Gender:F
Credentials:LMT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9381 N RINKER DR
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-8704
Mailing Address - Country:US
Mailing Address - Phone:954-478-2825
Mailing Address - Fax:
Practice Address - Street 1:3356 IRONBOUND RD BLDG 1
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2412
Practice Address - Country:US
Practice Address - Phone:757-744-7055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019014615225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist