Provider Demographics
NPI:1972041234
Name:FATEYEVA, NATALYA
Entity Type:Individual
Prefix:
First Name:NATALYA
Middle Name:
Last Name:FATEYEVA
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 1:2159 NW 76TH TER
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-3652
Mailing Address - Country:US
Mailing Address - Phone:954-707-8520
Mailing Address - Fax:
Practice Address - Street 1:12565 ORANGE DR STE 406
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-4310
Practice Address - Country:US
Practice Address - Phone:954-707-8520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT 2774106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist