Provider Demographics
NPI:1033810072
Name:FALES, MARIYAH KRYSTIN
Entity Type:Individual
Prefix:
First Name:MARIYAH
Middle Name:KRYSTIN
Last Name:FALES
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 955
Mailing Address - Street 2:
Mailing Address - City:GLEN
Mailing Address - State:NH
Mailing Address - Zip Code:03838-0955
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43 UNION ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-3133
Practice Address - Country:US
Practice Address - Phone:802-885-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician