Provider Demographics
NPI:1659120913
Name:FALLON, STACEY SERRELL (LCSW)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:SERRELL
Last Name:FALLON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6688 STONEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:VA
Mailing Address - Zip Code:20124-2538
Mailing Address - Country:US
Mailing Address - Phone:703-220-2489
Mailing Address - Fax:
Practice Address - Street 1:6688 STONEBROOK DR
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:VA
Practice Address - Zip Code:20124-2538
Practice Address - Country:US
Practice Address - Phone:703-220-2489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904013359101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty