Provider Demographics
NPI:1700343308
Name:FAVA, EVA (LPC)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:FAVA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:EVA
Other - Middle Name:
Other - Last Name:FAVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:322 LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07071-2103
Mailing Address - Country:US
Mailing Address - Phone:201-978-6198
Mailing Address - Fax:
Practice Address - Street 1:179 S MAPLE AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4541
Practice Address - Country:US
Practice Address - Phone:551-252-5270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00663800101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty