Provider Demographics
NPI:1710527916
Name:FALLON, DIANA KIMBERLY AVARY (MA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:KIMBERLY AVARY
Last Name:FALLON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:KIMBERLY
Other - Last Name:AVARY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:832 SUNNY GLEN COURT
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-6113
Mailing Address - Country:US
Mailing Address - Phone:650-714-4993
Mailing Address - Fax:
Practice Address - Street 1:832 SUNNY GLEN COURT
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-6113
Practice Address - Country:US
Practice Address - Phone:650-714-4993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT116501101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health