Organization
MATTHEW FAVA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MATTHEW JOSEPH FAVA III PSY.D, MFT (DOCTOR)
(209) 769-9554
Entity
Organization
Contact information
Practice address
404 W PINE ST, LODI, CA 95240-2048
(209) 769-9554
(209) 435-0894
Mailing address
507 YOKUTS DR, LODI, CA 95240-0690
(209) 769-9554
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
47392
CA
Other
Enumeration date
03/28/2007
Last updated
04/05/2012
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