Provider Demographics
NPI:1881950624
Name:FAVA, MATTHEW JOSEPH (PSYD, MFT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:FAVA
Suffix:
Gender:M
Credentials:PSYD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W PINE ST
Mailing Address - Street 2:SUTIE 1
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-2048
Mailing Address - Country:US
Mailing Address - Phone:209-769-9554
Mailing Address - Fax:209-435-0894
Practice Address - Street 1:404 W PINE ST
Practice Address - Street 2:SUTIE 1
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-2048
Practice Address - Country:US
Practice Address - Phone:209-769-9554
Practice Address - Fax:209-435-0894
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47392106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist