Provider Demographics
NPI:1851783187
Name:PERFORMANCE FALLON INC
Entity Type:Organization
Organization Name:PERFORMANCE FALLON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:FALLON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:928-460-4443
Mailing Address - Street 1:261 JACOB LN
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-5844
Mailing Address - Country:US
Mailing Address - Phone:847-323-2636
Mailing Address - Fax:928-460-4443
Practice Address - Street 1:143 E MERRITT ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2028
Practice Address - Country:US
Practice Address - Phone:928-460-4443
Practice Address - Fax:928-460-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4578103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty