Provider Demographics
NPI:1649364787
Name:LENNON, FAITH (PHD)
Entity type:Individual
Prefix:DR
First Name:FAITH
Middle Name:
Last Name:LENNON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 BELLE TERRE RD
Mailing Address - Street 2:BLDG. E, SUITE 3
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1936
Mailing Address - Country:US
Mailing Address - Phone:631-473-0996
Mailing Address - Fax:
Practice Address - Street 1:640 BELLE TERRE RD
Practice Address - Street 2:BLDG. E, SUITE 3
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1936
Practice Address - Country:US
Practice Address - Phone:631-473-0996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004756-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
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NYAJ00794AMedicare UPIN