Provider Demographics
NPI:1124499561
Name:FALLON, ABBEY RAIA (BSED, ATC, LAT)
Entity type:Individual
Prefix:
First Name:ABBEY
Middle Name:RAIA
Last Name:FALLON
Suffix:
Gender:F
Credentials:BSED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 WILDWOOD RD W
Mailing Address - Street 2:
Mailing Address - City:NORTHVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07647-1125
Mailing Address - Country:US
Mailing Address - Phone:201-741-1460
Mailing Address - Fax:
Practice Address - Street 1:619 WILDWOOD RD W
Practice Address - Street 2:
Practice Address - City:NORTHVALE
Practice Address - State:NJ
Practice Address - Zip Code:07647-1125
Practice Address - Country:US
Practice Address - Phone:201-741-1460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0031392255A2300X
NJ25MT00231002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer