Provider Demographics
NPI:1720464746
Name:FULUVAKA, MONA RAE
Entity type:Individual
Prefix:
First Name:MONA
Middle Name:RAE
Last Name:FULUVAKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MONA
Other - Middle Name:RAE
Other - Last Name:KEALOHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10259 YATES LN NW
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-9543
Mailing Address - Country:US
Mailing Address - Phone:360-536-3060
Mailing Address - Fax:347-823-9717
Practice Address - Street 1:3100 NW BUCKLIN HILL RD
Practice Address - Street 2:SUITE 224
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8358
Practice Address - Country:US
Practice Address - Phone:360-536-3060
Practice Address - Fax:347-823-9717
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60508326101Y00000X
WA0-16-7120106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor