Healthcare Provider Details

I. General information

NPI: 1801759956
Provider Name (Legal Business Name): TOKATA ETUNWAN WAKANYEZA OWICAKIYAPI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28572 BIA 1
ROSEBUD SD
57570
US

IV. Provider business mailing address

PO BOX 253
ROSEBUD SD
57570-0253
US

V. Phone/Fax

Practice location:
  • Phone: 605-515-3511
  • Fax:
Mailing address:
  • Phone: 605-515-3511
  • Fax: 605-515-3511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: CHARISSE NICHELLE BORDEAUX
Title or Position: DIRECTOR OF COUNSELOR EDUCATION
Credential: MS, LPC, NCC, QMHP
Phone: 605-515-3511