Provider Demographics
NPI:1194065110
Name:FALLON, SANDRA ANNE (LICSW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:ANNE
Last Name:FALLON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-1823
Mailing Address - Country:US
Mailing Address - Phone:508-765-9761
Mailing Address - Fax:
Practice Address - Street 1:29 PINE ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-1823
Practice Address - Country:US
Practice Address - Phone:508-765-9761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10162601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical