MEDICARE: KELLY FALLON MSW, LISW-S, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	254010	KY
2	1041C0700X	Clinical Social Worker	I.1201146-SUPV	OH
3	1041C0700X	Clinical Social Worker	254010	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194119941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY FALLON MSW, LISW-S, LCSW

Provider Business Mailing Address
First Line	:	8665 TUDOR CT
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45242-7836
Country	:	US
Telephone Number	:	513-771-7239
Fax Number	:

Provider Business Practice Location Address
First Line	:	4220 HOUSTON RD
Second Line	:
City	:	ERLANGER
State	:	KY
Zip	:	41018-3402
Country	:	US
Telephone Number	:	502-262-2887
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2015
Last Update Date	:	12/18/2020

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