Healthcare Provider Details

I. General information

NPI: 1568370435
Provider Name (Legal Business Name): FALLYN ELIZABETH HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4611 SE 100TH PL
BELLEVIEW FL
34420-3013
US

IV. Provider business mailing address

3580 N BURROUGHS PATH
BEVERLY HILLS FL
34465-4906
US

V. Phone/Fax

Practice location:
  • Phone: 618-520-4505
  • Fax:
Mailing address:
  • Phone: 618-520-4505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: