Provider Demographics
NPI:1902163900
Name:FATULA, ALEKSANDER
Entity type:Individual
Prefix:
First Name:ALEKSANDER
Middle Name:
Last Name:FATULA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MEGHAN LN
Mailing Address - Street 2:
Mailing Address - City:JUDSONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72081-9302
Mailing Address - Country:US
Mailing Address - Phone:501-729-4479
Mailing Address - Fax:501-729-3537
Practice Address - Street 1:707 W CENTER AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-5235
Practice Address - Country:US
Practice Address - Phone:501-827-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP0905027101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP0905027OtherLPC