Provider Demographics
NPI:1053457861
Name:FALLIN, RICHARD (MDIV)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:FALLIN
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 MOUNTAIN RUN
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35244-1930
Mailing Address - Country:US
Mailing Address - Phone:205-775-7757
Mailing Address - Fax:
Practice Address - Street 1:2344 VALLEYDALE ROAD
Practice Address - Street 2:SUITE #B
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35244
Practice Address - Country:US
Practice Address - Phone:205-775-7757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3085101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51533335OtherBCBS