Healthcare Provider Details

I. General information

NPI: 1811814452
Provider Name (Legal Business Name): NATALIA KHUDOKONENKO LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 N TREKELL RD STE 5
CASA GRANDE AZ
85122-1705
US

IV. Provider business mailing address

1270 E LAUREL CT
CASA GRANDE AZ
85122-2924
US

V. Phone/Fax

Practice location:
  • Phone: 623-243-2774
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-24165
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: