Provider Demographics
NPI:1922699107
Name:FALLON, TERESA OLIVIA (ADN, CMT)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:OLIVIA
Last Name:FALLON
Suffix:
Gender:F
Credentials:ADN, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2665 STONY POINT RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-7343
Mailing Address - Country:US
Mailing Address - Phone:707-548-1970
Mailing Address - Fax:707-867-1243
Practice Address - Street 1:726 MENDOCINO AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4804
Practice Address - Country:US
Practice Address - Phone:707-548-1970
Practice Address - Fax:707-867-1243
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85355225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist