Healthcare Provider Details

I. General information

NPI: 1972587319
Provider Name (Legal Business Name): JILL C FAVATA M.S. ED, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 BENT AVE THE HEALING CENTER
CHEYENNE WY
82001-2742
US

IV. Provider business mailing address

1213 TAFT AVE APT. B
CHEYENNE WY
82001-6860
US

V. Phone/Fax

Practice location:
  • Phone: 307-286-5279
  • Fax:
Mailing address:
  • Phone: 307-286-5279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number910
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number910
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: