Healthcare Provider Details

I. General information

NPI: 1689173627
Provider Name (Legal Business Name): JOHN KENNETH FALLS M.S. LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2018
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 48TH AVE N STE 202
MYRTLE BEACH SC
29577-5425
US

IV. Provider business mailing address

409 PLUMSTEAD CT
MYRTLE BEACH SC
29579-7081
US

V. Phone/Fax

Practice location:
  • Phone: 843-449-2576
  • Fax: 843-449-6851
Mailing address:
  • Phone: 410-474-3403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: