Provider Demographics
NPI:1073892790
Name:KODATT, ALINA MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:ALINA
Middle Name:MICHELLE
Last Name:KODATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 W 69TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-3808
Mailing Address - Country:US
Mailing Address - Phone:904-524-4004
Mailing Address - Fax:
Practice Address - Street 1:7235 BONNEVAL RD STE 104
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7506
Practice Address - Country:US
Practice Address - Phone:904-592-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13518101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health