Provider Demographics
NPI:1376376442
Name:FALLON, MICHAEL DESHAUN
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DESHAUN
Last Name:FALLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2369 CHICKASAW STREET
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-0017
Mailing Address - Country:US
Mailing Address - Phone:513-571-1149
Mailing Address - Fax:
Practice Address - Street 1:2369 CHICKASAW ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-0017
Practice Address - Country:US
Practice Address - Phone:513-571-1149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician