Provider Demographics
NPI:1205603487
Name:FALLON, KELSEA
Entity type:Individual
Prefix:
First Name:KELSEA
Middle Name:
Last Name:FALLON
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 1:16 SENTINEL TRL
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-5412
Mailing Address - Country:US
Mailing Address - Phone:352-239-9341
Mailing Address - Fax:
Practice Address - Street 1:16 SENTINEL TRL
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5412
Practice Address - Country:US
Practice Address - Phone:522-399-3413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician