Healthcare Provider Details

I. General information

NPI: 1114139565
Provider Name (Legal Business Name): COKATA LTD. LIABILITY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 RIDGECREST DR
SANTA FE NM
87505-6343
US

IV. Provider business mailing address

138 RIDGECREST DR
SANTA FE NM
87505-6343
US

V. Phone/Fax

Practice location:
  • Phone: 505-471-9154
  • Fax: 505-438-9592
Mailing address:
  • Phone: 505-471-9154
  • Fax: 505-438-9592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC0915
License Number StateNM

VIII. Authorized Official

Name: MR. RONALD LEE ANDES
Title or Position: CO-MANAGER
Credential: LPC
Phone: 505-438-9592