Basic Information
| Provider Information | |||||||||
| NPI: | 1053457861 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FALLIN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.DIV. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 573 COUNTY ROAD 1659 | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350587307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567961859 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1909 COMMERCE AVE | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350556151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567344688 | ||||||||
| FaxNumber: | 2567365638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 04/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 3085 | AL | N | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 51533335 | 01 | AL | BCBS | OTHER |