Provider Demographics
NPI:1023181708
Name:FAVALORO, KATHLEEN M (CHIROPRACTOR, PT)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:M
Last Name:FAVALORO
Suffix:
Gender:F
Credentials:CHIROPRACTOR, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:GREAT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230-0012
Mailing Address - Country:US
Mailing Address - Phone:413-528-5535
Mailing Address - Fax:
Practice Address - Street 1:19 LEWIS AVENUE
Practice Address - Street 2:
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230
Practice Address - Country:US
Practice Address - Phone:413-528-5535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2395111N00000X
NYX009242-1111N00000X
NY006800-1225100000X
MA12166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q04313OtherDC BCBS
Q04314OtherPT BCBS