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General NPI Number Information
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NPI Number | 1740613306
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Entity Type | Individual
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Provider Name | JUAN JOSE HERNANDEZ-CODALLOS
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Gender | Male
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Dates
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Enumeration Date | 08/17/2013
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Last Update Date | 07/31/2023
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Provider Practice Location Address
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Address Line | 615 ROGER CANYON RD
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City | LARAMIE
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State | WY
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Zip | 82072-8902
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Country | US
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Telephone | 209-918-8761
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1733
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City | LARAMIE
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State | WY
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Zip | 82073-1733
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 92529
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License Number State | CA
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