Healthcare Provider Details

I. General information

NPI: 1811351919
Provider Name (Legal Business Name): FALLON FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 W GRAND BLVD SUITE 450
DETROIT MI
48202-3046
US

IV. Provider business mailing address

3031 W GRAND BLVD SUITE 450
DETROIT MI
48202-3046
US

V. Phone/Fax

Practice location:
  • Phone: 313-346-5235
  • Fax:
Mailing address:
  • Phone: 313-346-5235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberS4135
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: