Provider Demographics
NPI:1851044747
Name:FATIAKI, KEONEKEALOHA PASIRIO
Entity Type:Individual
Prefix:
First Name:KEONEKEALOHA
Middle Name:PASIRIO
Last Name:FATIAKI
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 1:216 W LOS ANGELES DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-3101
Mailing Address - Country:US
Mailing Address - Phone:760-630-4065
Mailing Address - Fax:
Practice Address - Street 1:216 W LOS ANGELES DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-3101
Practice Address - Country:US
Practice Address - Phone:760-630-4065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA113918101YM0800X, 104100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program