Provider Demographics
NPI:1396860748
Name:FALLON, JOAN (OTR)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:FALLON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5561 ALEXANDRITE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8377
Mailing Address - Country:US
Mailing Address - Phone:803-396-0263
Mailing Address - Fax:
Practice Address - Street 1:8919 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-7629
Practice Address - Country:US
Practice Address - Phone:704-551-7100
Practice Address - Fax:704-295-0013
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3438225X00000X
SC2405225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist