Provider Demographics
NPI:1518964824
Name:FAVER, LEE MITCHELL (PHD ABPP)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:MITCHELL
Last Name:FAVER
Suffix:
Gender:M
Credentials:PHD ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5927 SE COLUMBIA WAY UNIT 203
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-6381
Mailing Address - Country:US
Mailing Address - Phone:360-524-3616
Mailing Address - Fax:
Practice Address - Street 1:303 E 16TH ST STE 111
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3410
Practice Address - Country:US
Practice Address - Phone:360-524-3616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60285535103TC1900X
WAPY 60285535103TC1900X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA2549Medicare ID - Type UnspecifiedMEDICARE INDIV PROVIDER#