Provider Demographics
NPI:1336634450
Name:O'FALLON, GAYLA JOYCE (LPC, MAC)
Entity Type:Individual
Prefix:MS
First Name:GAYLA
Middle Name:JOYCE
Last Name:O'FALLON
Suffix:
Gender:F
Credentials:LPC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32065 CASTLE CT STE 205
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-9586
Mailing Address - Country:US
Mailing Address - Phone:720-837-4724
Mailing Address - Fax:720-504-7787
Practice Address - Street 1:32065 CASTLE CT STE 205
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-9586
Practice Address - Country:US
Practice Address - Phone:720-837-4724
Practice Address - Fax:720-504-7787
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-30
Last Update Date:2018-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3294101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO$$$$$$$$$OtherFEDERAL EIN