Provider Demographics
NPI:1962220319
Name:FANGUPO, TANIELA MA'U
Entity type:Individual
Prefix:MR
First Name:TANIELA
Middle Name:MA'U
Last Name:FANGUPO
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 1:1385 S STATE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-5584
Mailing Address - Country:US
Mailing Address - Phone:801-897-4703
Mailing Address - Fax:
Practice Address - Street 1:1385 S STATE ST STE 400
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-5584
Practice Address - Country:US
Practice Address - Phone:801-897-4703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker