Healthcare Provider Details

I. General information

NPI: 1487766127
Provider Name (Legal Business Name): SANDRA J FALLON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4624 JOHNSON AVE
WESTERN SPRINGS IL
60558
US

IV. Provider business mailing address

4624 JOHNSON AVE
WESTERN SPRINGS IL
60558
US

V. Phone/Fax

Practice location:
  • Phone: 708-203-9845
  • Fax: 708-246-3408
Mailing address:
  • Phone: 708-203-9845
  • Fax: 708-246-3408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071005007
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041094355
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: