Provider Demographics
NPI:1578630364
Name:FALLIS, EMILY ALINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:EMILY
Middle Name:ALINE
Last Name:FALLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11592
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-0592
Mailing Address - Country:US
Mailing Address - Phone:817-366-3577
Mailing Address - Fax:817-921-6939
Practice Address - Street 1:1005 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-5087
Practice Address - Country:US
Practice Address - Phone:214-941-1650
Practice Address - Fax:214-941-8008
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25143103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic