Provider Demographics
NPI:1497296313
Name:FALLON, RYAN PATRICK (OT)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:PATRICK
Last Name:FALLON
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4466 W BRISTOL RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3170
Mailing Address - Country:US
Mailing Address - Phone:810-733-1200
Mailing Address - Fax:810-733-0688
Practice Address - Street 1:4282 W VIENNA RD
Practice Address - Street 2:
Practice Address - City:CLIO
Practice Address - State:MI
Practice Address - Zip Code:48420-9454
Practice Address - Country:US
Practice Address - Phone:810-564-2400
Practice Address - Fax:810-564-9994
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009713225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1497296313Medicaid