Provider Demographics
NPI:1942939848
Name:MAKOTO, AUDRIANA
Entity Type:Individual
Prefix:
First Name:AUDRIANA
Middle Name:
Last Name:MAKOTO
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 1:1912 ROBBINS ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1111
Mailing Address - Country:US
Mailing Address - Phone:912-666-0690
Mailing Address - Fax:
Practice Address - Street 1:7710 E BRAINERD RD APT 1201
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-5925
Practice Address - Country:US
Practice Address - Phone:912-666-0690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty