Provider Demographics
NPI:1639969264
Name:KOA MENTAL HEALTH LLC
Entity type:Organization
Organization Name:KOA MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:808-333-8094
Mailing Address - Street 1:4217 W WINTER EVENING PL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-7198
Mailing Address - Country:US
Mailing Address - Phone:808-333-8094
Mailing Address - Fax:
Practice Address - Street 1:1034 ULANA PL
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3261
Practice Address - Country:US
Practice Address - Phone:808-333-8094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)