Healthcare Provider Details

I. General information

NPI: 1194119941
Provider Name (Legal Business Name): KELLY FALLON MSW, LISW-S, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 HOUSTON RD
ERLANGER KY
41018-3402
US

IV. Provider business mailing address

8665 TUDOR CT
CINCINNATI OH
45242-7836
US

V. Phone/Fax

Practice location:
  • Phone: 502-262-2887
  • Fax:
Mailing address:
  • Phone: 513-771-7239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number254010
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1201146-SUPV
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number254010
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: