Provider Demographics
NPI:1770857179
Name:FAVAZZA, MELISSA (LSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FAVAZZA
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8261 BARBARA DR
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44136-1918
Mailing Address - Country:US
Mailing Address - Phone:440-570-0682
Mailing Address - Fax:
Practice Address - Street 1:10000 BRECKSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141
Practice Address - Country:US
Practice Address - Phone:216-701-7630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0030953104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker