Provider Demographics
NPI:1548455801
Name:FALLON, SAMANTHA ROSE (BA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ROSE
Last Name:FALLON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 BROOKHOLLOW DR
Mailing Address - Street 2:SUITE 114
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5418
Mailing Address - Country:US
Mailing Address - Phone:714-432-8584
Mailing Address - Fax:
Practice Address - Street 1:1504 BROOKHOLLOW DR
Practice Address - Street 2:SUITE 113
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5418
Practice Address - Country:US
Practice Address - Phone:714-432-8584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor