Healthcare Provider Details

I. General information

NPI: 1922398346
Provider Name (Legal Business Name): DIANE MALONE KUDOLO LPC, CART
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 N COMAL
SAN ANTONIO TX
78207
US

IV. Provider business mailing address

7305 SUNSCAPE WAY
SAN ANTONIO TX
78204
US

V. Phone/Fax

Practice location:
  • Phone: 210-213-5780
  • Fax:
Mailing address:
  • Phone: 210-213-5780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number65512
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: