Provider Demographics
NPI:1669620050
Name:LALLY, JULIANA (LCSW)
Entity type:Individual
Prefix:
First Name:JULIANA
Middle Name:
Last Name:LALLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 PARTRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-1943
Mailing Address - Country:US
Mailing Address - Phone:314-854-5738
Mailing Address - Fax:314-854-5750
Practice Address - Street 1:1340 PARTRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-1943
Practice Address - Country:US
Practice Address - Phone:314-854-5738
Practice Address - Fax:314-854-5750
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0014481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495961609Medicaid