Provider Demographics
NPI:1306137740
Name:FONOTISATELE, UALAPA MIKA JR (BA)
Entity type:Individual
Prefix:MR
First Name:UALAPA
Middle Name:MIKA
Last Name:FONOTISATELE
Suffix:JR
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 KEATING ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-5931
Mailing Address - Country:US
Mailing Address - Phone:702-998-6264
Mailing Address - Fax:702-998-6270
Practice Address - Street 1:359 KEATING ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-5931
Practice Address - Country:US
Practice Address - Phone:702-998-6264
Practice Address - Fax:702-998-6270
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1401410384101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor