Provider Demographics
NPI:1053788190
Name:FAVICHIA, CLARISSA A (LMHC)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:A
Last Name:FAVICHIA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-2051
Mailing Address - Country:US
Mailing Address - Phone:631-332-2008
Mailing Address - Fax:
Practice Address - Street 1:1380 ROANOKE AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2098
Practice Address - Country:US
Practice Address - Phone:631-369-0022
Practice Address - Fax:631-369-5336
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006740101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health