Provider Demographics
NPI:1487185518
Name:TIALAVEA, KERESOMA
Entity type:Individual
Prefix:
First Name:KERESOMA
Middle Name:
Last Name:TIALAVEA
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 1:1109 W COLLEGE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-4100
Mailing Address - Country:US
Mailing Address - Phone:415-730-2365
Mailing Address - Fax:
Practice Address - Street 1:1109 W COLLEGE AVE APT 2
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-4100
Practice Address - Country:US
Practice Address - Phone:415-730-2365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician