Healthcare Provider Details

I. General information

NPI: 1316352958
Provider Name (Legal Business Name): ALEXIS MITSUKO KAMAKANOE ORNELLAS LPC, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2635 MAPLETON AVE LOT 24
BOULDER CO
80304-3828
US

IV. Provider business mailing address

2635 MAPLETON AVE LOT 24
BOULDER CO
80304-3828
US

V. Phone/Fax

Practice location:
  • Phone: 720-408-5393
  • Fax:
Mailing address:
  • Phone: 720-408-5393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACD.0000422
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC.0012209
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: