Provider Demographics
NPI:1104214170
Name:FAVSTRITSKY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FAVSTRITSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 S RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89406-3722
Mailing Address - Country:US
Mailing Address - Phone:775-217-4325
Mailing Address - Fax:
Practice Address - Street 1:40 E CENTER ST STE 12
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89406-3474
Practice Address - Country:US
Practice Address - Phone:775-867-5615
Practice Address - Fax:775-867-5616
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health