Healthcare Provider Details

I. General information

NPI: 1538464417
Provider Name (Legal Business Name): JOSHUA CHARLES FELVER PHD ABPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOSHUA CHARLES FELVER-GANT MS

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E BUFFALO ST
ITHACA NY
14850-4266
US

IV. Provider business mailing address

120 E BUFFALO ST
ITHACA NY
14850-4266
US

V. Phone/Fax

Practice location:
  • Phone: 607-233-4337
  • Fax:
Mailing address:
  • Phone: 607-233-4337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number021949
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: