Healthcare Provider Details

I. General information

NPI: 1083298590
Provider Name (Legal Business Name): LAURA FAIWISZEWSKI PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8705 BAY CT
CAPE CANAVERAL FL
32920-2035
US

IV. Provider business mailing address

27 CRESTWOOD DR
WEST ORANGE NJ
07052-2003
US

V. Phone/Fax

Practice location:
  • Phone: 516-831-0128
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number025259
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY13114
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: