Healthcare Provider Details

I. General information

NPI: 1508760323
Provider Name (Legal Business Name): KATIARA M FALLON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1912 DAIRY RD
WEST MELBOURNE FL
32904-4046
US

IV. Provider business mailing address

3299 DADE CIR NE
PALM BAY FL
32905-6020
US

V. Phone/Fax

Practice location:
  • Phone: 321-413-3366
  • Fax:
Mailing address:
  • Phone: 321-682-8082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: