Healthcare Provider Details

I. General information

NPI: 1417367566
Provider Name (Legal Business Name): FALLON BURCH LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1048 ASHLEY ST
BOWLING GREEN KY
42103-2449
US

IV. Provider business mailing address

1048 ASHLEY ST
BOWLING GREEN KY
42103-2449
US

V. Phone/Fax

Practice location:
  • Phone: 270-904-6567
  • Fax: 270-904-6570
Mailing address:
  • Phone: 270-904-6567
  • Fax: 270-904-6570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1733
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: