Provider Demographics
NPI:1154394104
Name:FAVIA, PATRICIA M (PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:FAVIA
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 OGDEN AVE
Mailing Address - Street 2:LL5
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-2865
Mailing Address - Country:US
Mailing Address - Phone:630-968-1181
Mailing Address - Fax:630-322-9977
Practice Address - Street 1:1001 OGDEN AVE
Practice Address - Street 2:LL5
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2865
Practice Address - Country:US
Practice Address - Phone:630-968-1181
Practice Address - Fax:630-322-9977
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004677103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL82737Medicare ID - Type UnspecifiedMED GRP PMHS
IL207982Medicare ID - Type Unspecified
ILK10994Medicare ID - Type Unspecified