Provider Demographics
NPI:1871305656
Name:FAVA, BROOKE ANGELA (BCBA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ANGELA
Last Name:FAVA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 OLIVIA WAY
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08515-2940
Mailing Address - Country:US
Mailing Address - Phone:908-397-2957
Mailing Address - Fax:
Practice Address - Street 1:52 OLIVIA WAY
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08515-2940
Practice Address - Country:US
Practice Address - Phone:908-397-2957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-23-69449103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty