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General NPI Number Information
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NPI Number | 1639969264
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Entity Type | Organization
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Legal Business Name | KOA MENTAL HEALTH LLC
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Dates
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Enumeration Date | 05/07/2025
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Last Update Date | 05/07/2025
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Provider Practice Location Address
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Address Line | 1034 ULANA PL
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City | HILO
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State | HI
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Zip | 96720-3261
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Country | US
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Telephone | 808-333-8094
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Fax |
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Provider Business Mailing Address
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Address Line | 4217 W WINTER EVENING PL
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City | FAYETTEVILLE
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State | AR
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Zip | 72704-7198
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Country | US
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Telephone | 808-333-8094
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Fax |
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Authorized Official
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Title or Position | OWNER/OPERATER
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Name | JOSEPH DANIEL GOMEZ
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Credential | LMHC
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Telephone | 808-333-8094
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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