Provider Demographics
NPI:1295331973
Name:RISSO, FAYTH
Entity type:Individual
Prefix:
First Name:FAYTH
Middle Name:
Last Name:RISSO
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 1:8 DELMORE DR
Mailing Address - Street 2:
Mailing Address - City:KENDALL PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08824-7015
Mailing Address - Country:US
Mailing Address - Phone:908-268-2689
Mailing Address - Fax:
Practice Address - Street 1:515 TRINITY PL
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-3369
Practice Address - Country:US
Practice Address - Phone:908-268-2689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00420200101YM0800X
NJ37PC00744000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health