Provider Demographics
NPI:1477601607
Name:FALLIN, KENNETH J (MSSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:FALLIN
Suffix:
Gender:M
Credentials:MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 SADDLEBROOK DR S
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-5336
Mailing Address - Country:US
Mailing Address - Phone:817-253-4773
Mailing Address - Fax:817-282-7738
Practice Address - Street 1:750 N FIELDER RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4635
Practice Address - Country:US
Practice Address - Phone:817-253-4773
Practice Address - Fax:817-282-7738
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX192381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical