Provider Demographics
NPI:1023292158
Name:KODAD, VICKI
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:KODAD
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 1:12712 HEACOCK ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-3037
Mailing Address - Country:US
Mailing Address - Phone:951-243-5576
Mailing Address - Fax:
Practice Address - Street 1:12712 HEACOCK ST
Practice Address - Street 2:SUITE 6
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3037
Practice Address - Country:US
Practice Address - Phone:951-243-5576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAADE051086101Y00000X
CA101YM0800X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health