=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821117284
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATTHEW FAVA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2007
-----------------------------------------------------
Last Update Date | 04/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 W PINE ST
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95240-2048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-769-9554
-----------------------------------------------------
Fax | 209-435-0894
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 507 YOKUTS DR
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95240-0690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-769-9554
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | MATTHEW JOSEPH FAVA III
-----------------------------------------------------
Credential | PSY.D, MFT
-----------------------------------------------------
Telephone | 209-769-9554
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 47392
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------