Provider Demographics
NPI:1952386708
Name:FALLON, DANIEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:FALLON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 E MERRITT ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-2028
Mailing Address - Country:US
Mailing Address - Phone:928-460-4443
Mailing Address - Fax:928-379-7091
Practice Address - Street 1:143 E MERRITT ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2028
Practice Address - Country:US
Practice Address - Phone:928-460-4443
Practice Address - Fax:928-379-7091
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005875103TC0700X
AZ4578103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P83884Medicare UPIN
205092Medicare ID - Type Unspecified