Provider Demographics
NPI:1366292070
Name:FALLOS, ISABELLA (SAC-IT)
Entity type:Individual
Prefix:
First Name:ISABELLA
Middle Name:
Last Name:FALLOS
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:IZZY
Other - Middle Name:
Other - Last Name:FALLOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SAC-IT
Mailing Address - Street 1:W2981 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:RIB LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54470-9704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:533 PEACE PIPE RD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-9123
Practice Address - Country:US
Practice Address - Phone:715-588-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20481-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)