Provider Demographics
NPI:1588836944
Name:FAVERO, DOMENICA KATHLEEN
Entity Type:Individual
Prefix:
First Name:DOMENICA
Middle Name:KATHLEEN
Last Name:FAVERO
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:PO BOX 11768
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24506-1768
Mailing Address - Country:US
Mailing Address - Phone:434-947-8290
Mailing Address - Fax:
Practice Address - Street 1:1900 THOMSON DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1009
Practice Address - Country:US
Practice Address - Phone:434-947-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003442103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical