Basic Information
| Provider Information | |||||||||
| NPI: | 1720068323 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FALLEN | ||||||||
| FirstName: | TAYA | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, CGC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YOUNG | ||||||||
| OtherFirstName: | TAYA | ||||||||
| OtherMiddleName: | JO | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, CGC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2655 W CORTEZ ST | ||||||||
| Address2: | UNIT 2 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606223416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735054225 | ||||||||
| FaxNumber: | 3126950318 | ||||||||
| Practice Location | |||||||||
| Address1: | 676 N SAINT CLAIR ST | ||||||||
| Address2: | SUITE 880 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126950320 | ||||||||
| FaxNumber: | 3126950318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | ABMG/ABGC 2002373 | IL | Y | Other Service Providers | Genetic Counselor, MS |
No ID Information.