Healthcare Provider Details

I. General information

NPI: 1124497599
Provider Name (Legal Business Name): MICHAEL NICHOLAS FATULA LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SANGERS LN
STAUNTON VA
24401-6712
US

IV. Provider business mailing address

85 SANGERS LN
STAUNTON VA
24401-6712
US

V. Phone/Fax

Practice location:
  • Phone: 540-887-3200
  • Fax: 540-887-3258
Mailing address:
  • Phone: 540-887-3200
  • Fax: 540-887-3258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701006261
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: