Provider Demographics
NPI:1720068323
Name:FALLEN, TAYA JO (MS, CGC)
Entity Type:Individual
Prefix:MS
First Name:TAYA
Middle Name:JO
Last Name:FALLEN
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:MS
Other - First Name:TAYA
Other - Middle Name:JO
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CGC
Mailing Address - Street 1:2655 W CORTEZ ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3416
Mailing Address - Country:US
Mailing Address - Phone:773-505-4225
Mailing Address - Fax:312-695-0318
Practice Address - Street 1:676 N SAINT CLAIR ST
Practice Address - Street 2:SUITE 880
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-695-0320
Practice Address - Fax:312-695-0318
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILABMG/ABGC 2002373170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS