Provider Demographics
NPI:1679938252
Name:FAILLA, DEBRA MARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:MARIE
Last Name:FAILLA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 MAIN STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:260 MAIN STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768
Practice Address - Country:US
Practice Address - Phone:631-784-7761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018181103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical