Healthcare Provider Details

I. General information

NPI: 1043758964
Provider Name (Legal Business Name): CYNTHIA TANAKA COUNSELING AND CONSULTING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2017
Last Update Date: 02/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 WEST AVE
ALAMOSA CO
81101-3028
US

IV. Provider business mailing address

PO BOX 313
ALAMOSA CO
81101-0313
US

V. Phone/Fax

Practice location:
  • Phone: 719-588-6578
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5724
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5724
License Number StateCO

VIII. Authorized Official

Name: CYNTHIA TANAKA
Title or Position: OWNER
Credential: LPC
Phone: 719-588-6578