Provider Demographics
NPI:1801947569
Name:KEITH FALLON, PSY.D., P.C.
Entity type:Organization
Organization Name:KEITH FALLON, PSY.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:FALLON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:404-502-5824
Mailing Address - Street 1:PO BOX 1790
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-7964
Mailing Address - Country:US
Mailing Address - Phone:404-502-5824
Mailing Address - Fax:
Practice Address - Street 1:1100 GREEN ST SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-5220
Practice Address - Country:US
Practice Address - Phone:404-502-5824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002856103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty