Provider Demographics
NPI:1487980611
Name:PETELO, TISHA (LCSW, MAC)
Entity type:Individual
Prefix:MRS
First Name:TISHA
Middle Name:
Last Name:PETELO
Suffix:
Gender:F
Credentials:LCSW, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1005
Mailing Address - Street 2:
Mailing Address - City:PAGO PAGO
Mailing Address - State:AS
Mailing Address - Zip Code:96799-1005
Mailing Address - Country:US
Mailing Address - Phone:684-699-3725
Mailing Address - Fax:
Practice Address - Street 1:FIATELE TEO BLDG.
Practice Address - Street 2:AIRPORT ROAD 1005
Practice Address - City:PAGO PAGO
Practice Address - State:AS
Practice Address - Zip Code:96799-1005
Practice Address - Country:US
Practice Address - Phone:684-699-3725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical