Provider Demographics
NPI:1770841264
Name:FALL, KEVIN ANTHONY (LPC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ANTHONY
Last Name:FALL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 MANCHACA RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-6631
Mailing Address - Country:US
Mailing Address - Phone:512-757-4949
Mailing Address - Fax:
Practice Address - Street 1:3625 MANCHACA RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-6631
Practice Address - Country:US
Practice Address - Phone:512-757-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13958101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional