Provider Demographics
NPI:1699977298
Name:FAVETTA, FRED JOSEPH (MA, CCC-A)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:JOSEPH
Last Name:FAVETTA
Suffix:
Gender:M
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 TALLMADGE RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-8218
Mailing Address - Country:US
Mailing Address - Phone:330-678-4646
Mailing Address - Fax:
Practice Address - Street 1:2400 TALLMADGE RD
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-8218
Practice Address - Country:US
Practice Address - Phone:330-678-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA-0429237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0643665Medicaid