Healthcare Provider Details

I. General information

NPI: 1205032299
Provider Name (Legal Business Name): KYOKO SONODA MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 SAN MATEO BLVD NE
ALBUQUERQUE NM
87108-1432
US

IV. Provider business mailing address

617 SAN MATEO BLVD NE
ALBUQUERQUE NM
87108-1432
US

V. Phone/Fax

Practice location:
  • Phone: 505-553-0388
  • Fax:
Mailing address:
  • Phone: 505-553-0388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0105511
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: