Basic Information
| Provider Information | |||||||||
| NPI: | 1952940629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FALLARA | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | TIMOTHY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5254 CAPE COD LN | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432354007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144598427 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1335 DUBLIN RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432151000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145380353 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2019 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | C.1700731-TRNE | OH | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | C.1700731-TRNE | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.