Healthcare Provider Details

I. General information

NPI: 1073510384
Provider Name (Legal Business Name): LEE M. FAVER PHD PSYCHOLOGIST PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 RADCLIFFE RD
BUFFALO NY
14214-1221
US

IV. Provider business mailing address

12 RADCLIFFE RD
BUFFALO NY
14214-1221
US

V. Phone/Fax

Practice location:
  • Phone: 716-553-3319
  • Fax:
Mailing address:
  • Phone: 716-553-3319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number011953
License Number StateNY

VIII. Authorized Official

Name: DR. LEE MITCH FAVER
Title or Position: PRESIDENT; LICENSED PSYCHOLOGIST
Credential: PHD ABPP
Phone: 716-553-3319