Provider Demographics
NPI:1205697893
Name:YOUR FAVORITE THERAPIST
Entity type:Organization
Organization Name:YOUR FAVORITE THERAPIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVYNTE
Authorized Official - Middle Name:
Authorized Official - Last Name:PANNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:973-327-3134
Mailing Address - Street 1:PO BOX 20380
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07101-6380
Mailing Address - Country:US
Mailing Address - Phone:973-327-3134
Mailing Address - Fax:
Practice Address - Street 1:2 FEDERAL SQ
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07101-2901
Practice Address - Country:US
Practice Address - Phone:301-848-9608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health