=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053788190
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLARISSA A FAVICHIA LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2015
-----------------------------------------------------
Last Update Date | 09/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1380 ROANOKE AVE 1ST FLOOR
-----------------------------------------------------
City | RIVERHEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11901-2098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-369-0022
-----------------------------------------------------
Fax | 631-369-5336
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 355 WOODLAND AVE
-----------------------------------------------------
City | MANORVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11949-2051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-332-2008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 006740
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------