Provider Demographics
NPI:1629546353
Name:URBANAVAGE, FALLON ALEXANDRA
Entity Type:Individual
Prefix:MRS
First Name:FALLON
Middle Name:ALEXANDRA
Last Name:URBANAVAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FALLON
Other - Middle Name:ALEXANDRA
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8237 VICELA DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34240-1462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 N PALAFOX ST STE 103
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-2678
Practice Address - Country:US
Practice Address - Phone:800-210-0814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL02011145106E00000X
FLRBT-18-67637106S00000X
12153748103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician