Provider Demographics
NPI:1285789222
Name:FALLON, JOSEPH HENRY JR (PHD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:HENRY
Last Name:FALLON
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 HERRINGTON RD
Mailing Address - Street 2:BLDG 2
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5649
Mailing Address - Country:US
Mailing Address - Phone:770-962-1944
Mailing Address - Fax:770-962-1886
Practice Address - Street 1:1805 HERRINGTON RD
Practice Address - Street 2:BLDG 2
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5649
Practice Address - Country:US
Practice Address - Phone:770-962-1944
Practice Address - Fax:770-962-1886
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001056103TC0700X, 103TH0100X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBBCJMedicare ID - Type Unspecified