Provider Demographics
NPI:1568022580
Name:WILLY, FATALY
Entity Type:Individual
Prefix:
First Name:FATALY
Middle Name:
Last Name:WILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 NANAKAI ST
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-2747
Mailing Address - Country:US
Mailing Address - Phone:808-745-9145
Mailing Address - Fax:
Practice Address - Street 1:500 ALAMOANA BLVD #7-400
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813
Practice Address - Country:US
Practice Address - Phone:808-745-9145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst