Individual
MOMODOUBOLONG FAITALA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
3105 LAKESHORE DR STE A101, ANCHORAGE, AK 99517-2815
(907) 302-9164
Mailing address
PO BOX 241224, ANCHORAGE, AK 99524-1224
(907) 302-9164
(209) 759-2653
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
106S00000X
Behavior Technician
Primary
RBT-21-196652
AK
Other
Enumeration date
01/19/2021
Last updated
12/17/2021
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