Provider Demographics
NPI:1043360951
Name:FALLON, SANTIAGO (LMHC)
Entity type:Individual
Prefix:MR
First Name:SANTIAGO
Middle Name:
Last Name:FALLON
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E. PANAMA RD.
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708
Mailing Address - Country:US
Mailing Address - Phone:407-462-6133
Mailing Address - Fax:407-332-6226
Practice Address - Street 1:1385 W STATE ROAD 434
Practice Address - Street 2:SUITE 103
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-6871
Practice Address - Country:US
Practice Address - Phone:407-462-6133
Practice Address - Fax:407-332-6226
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7320101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7647107 00Medicaid