=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740002799
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIZ FAVA COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2024
-----------------------------------------------------
Last Update Date | 10/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4840 ROSWELL RD STE C202
-----------------------------------------------------
City | SANDY SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-2633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-257-6474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4840 ROSWELL RD STE C202
-----------------------------------------------------
City | SANDY SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-2633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-257-6474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELIZABETH FAVA
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 813-300-6525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------