Provider Demographics
NPI:1114035235
Name:FATULA, MIKE (MS, MFT)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:FATULA
Suffix:
Gender:M
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7985 SANTA MONICA BLVD
Mailing Address - Street 2:#109 - 18
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-5074
Mailing Address - Country:US
Mailing Address - Phone:323-422-9433
Mailing Address - Fax:323-876-8941
Practice Address - Street 1:519 N LA CIENEGA BLVD
Practice Address - Street 2:#16
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-2007
Practice Address - Country:US
Practice Address - Phone:323-422-9433
Practice Address - Fax:323-876-8941
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAM15257106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist