Basic Information
| Provider Information | |||||||||
| NPI: | 1730278854 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAVREAU | ||||||||
| FirstName: | WAYNE | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2551 COORS BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871201213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053383320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1302 CALLE DE LA MERCED | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875322624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057470081 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 10/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0100411 | NM | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 0100411 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | XXXXXXX | 05 | NM | MEDICAID |