Provider Demographics
NPI:1417367566
Name:BURCH, FALLON (LPCC)
Entity Type:Individual
Prefix:
First Name:FALLON
Middle Name:
Last Name:BURCH
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 ASHLEY ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-2449
Mailing Address - Country:US
Mailing Address - Phone:270-904-6567
Mailing Address - Fax:270-904-6570
Practice Address - Street 1:1048 ASHLEY ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-2449
Practice Address - Country:US
Practice Address - Phone:270-904-6567
Practice Address - Fax:270-904-6570
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1733101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health