Provider Demographics
NPI:1629552104
Name:FAVAZZA, NICHOLE M
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:M
Last Name:FAVAZZA
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 1:115 WOLFS LN APT 3
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NY
Mailing Address - Zip Code:10803-1839
Mailing Address - Country:US
Mailing Address - Phone:914-714-1187
Mailing Address - Fax:
Practice Address - Street 1:59 DANBURY RD
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-4405
Practice Address - Country:US
Practice Address - Phone:203-210-7124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT657103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst