Healthcare Provider Details

I. General information

NPI: 1518964824
Provider Name (Legal Business Name): LEE MITCHELL FAVER PHD ABPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 03/03/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E 16TH ST STE 111
VANCOUVER WA
98663-3410
US

IV. Provider business mailing address

5927 SE COLUMBIA WAY UNIT 203
VANCOUVER WA
98661-6381
US

V. Phone/Fax

Practice location:
  • Phone: 360-524-3616
  • Fax:
Mailing address:
  • Phone: 360-524-3616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY60285535
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY 60285535
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: