Provider Demographics
NPI:1154016616
Name:DESIR, FALLON (PSYD)
Entity type:Individual
Prefix:
First Name:FALLON
Middle Name:
Last Name:DESIR
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 SAWGRASS CORPORATE PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:THE PALACE AT WESTON
Practice Address - Street 2:16025 EMERALD ESTATES DRIVE
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-6130
Practice Address - Country:US
Practice Address - Phone:954-217-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11795103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical