Provider Demographics
NPI:1922463298
Name:FALL, MAMADOU (LPCC)
Entity Type:Individual
Prefix:
First Name:MAMADOU
Middle Name:
Last Name:FALL
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 S 4TH ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40208-2314
Mailing Address - Country:US
Mailing Address - Phone:502-650-3804
Mailing Address - Fax:
Practice Address - Street 1:1300 S 4TH ST
Practice Address - Street 2:SUITE 240
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-2314
Practice Address - Country:US
Practice Address - Phone:502-650-3804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1319101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor