Provider Demographics
NPI:1851325567
Name:O'FALLON, KATHY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:
Last Name:O'FALLON
Suffix:
Gender:F
Credentials:PSYD
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 614
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-0614
Mailing Address - Country:US
Mailing Address - Phone:909-336-7278
Mailing Address - Fax:909-336-6282
Practice Address - Street 1:2239 GIRD RD
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-8894
Practice Address - Country:US
Practice Address - Phone:858-342-6434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12194103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP12194Medicare UPIN