Healthcare Provider Details

I. General information

NPI: 1164700035
Provider Name (Legal Business Name): DANIELE C KOKIDAJO LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 TIJERAS AVE NW
ALBUQUERQUE NM
87102-3096
US

IV. Provider business mailing address

7930 RANCHO DE PALOMAS NE
ALBUQUERQUE NM
87109-6078
US

V. Phone/Fax

Practice location:
  • Phone: 505-243-2223
  • Fax:
Mailing address:
  • Phone: 505-321-4160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0147221
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: