=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801759956
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOKATA ETUNWAN WAKANYEZA OWICAKIYAPI
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2025
-----------------------------------------------------
Last Update Date | 12/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28572 BIA 1
-----------------------------------------------------
City | ROSEBUD
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-515-3511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 253
-----------------------------------------------------
City | ROSEBUD
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57570-0253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-515-3511
-----------------------------------------------------
Fax | 605-515-3511
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF COUNSELOR EDUCATION
-----------------------------------------------------
Name | CHARISSE NICHELLE BORDEAUX
-----------------------------------------------------
Credential | MS, LPC, NCC, QMHP
-----------------------------------------------------
Telephone | 605-515-3511
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------