Provider Demographics
NPI:1104443407
Name:FALL, KHADY
Entity type:Individual
Prefix:MRS
First Name:KHADY
Middle Name:
Last Name:FALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 TULLY RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95111-1048
Mailing Address - Country:US
Mailing Address - Phone:408-896-4982
Mailing Address - Fax:
Practice Address - Street 1:1887 MONTEREY ROAD
Practice Address - Street 2:SUITE 205
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112
Practice Address - Country:US
Practice Address - Phone:408-961-4040
Practice Address - Fax:402-292-3640
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36947106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician