Healthcare Provider Details

I. General information

NPI: 1053788190
Provider Name (Legal Business Name): CLARISSA A FAVICHIA LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2015
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 ROANOKE AVE 1ST FLOOR
RIVERHEAD NY
11901-2098
US

IV. Provider business mailing address

355 WOODLAND AVE
MANORVILLE NY
11949-2051
US

V. Phone/Fax

Practice location:
  • Phone: 631-369-0022
  • Fax: 631-369-5336
Mailing address:
  • Phone: 631-332-2008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number006740
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: