Basic Information
| Provider Information | |||||||||
| NPI: | 1285725689 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LALLY | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | TERRANCE | ||||||||
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| Credential: | PHD PSYCHOLOGIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14900 | ||||||||
| Address2: | STATE OF OREGON IRS UNIT | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973095016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039459840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1121 NE 2ND | ||||||||
| Address2: | OREGON STATE HOSPITAL | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037318656 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 712 | OR | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.