Provider Demographics
NPI:1780742056
Name:FAILLACE, JOSEPH J (PHD LMHC)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:J
Last Name:FAILLACE
Suffix:
Gender:M
Credentials:PHD LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34-21 77TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON HTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6143
Mailing Address - Country:US
Mailing Address - Phone:718-779-2434
Mailing Address - Fax:
Practice Address - Street 1:3764 72ND ST
Practice Address - Street 2:OCNI
Practice Address - City:JACKSON HTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6143
Practice Address - Country:US
Practice Address - Phone:718-335-3434
Practice Address - Fax:718-335-4731
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001717101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health