Provider Demographics
NPI:1710425087
Name:FARAONI, JUAN III (LPC, LMHC)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:FARAONI
Suffix:III
Gender:M
Credentials:LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 EDGEMERE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-1003
Mailing Address - Country:US
Mailing Address - Phone:617-908-1228
Mailing Address - Fax:
Practice Address - Street 1:1581 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-4602
Practice Address - Country:US
Practice Address - Phone:617-908-1228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3078101YP2500X
MA11153101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional