Provider Demographics
NPI:1669143848
Name:KAKOURIS, ATHENA
Entity type:Individual
Prefix:
First Name:ATHENA
Middle Name:
Last Name:KAKOURIS
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 1:65896 CAHUILLA AVE
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-3828
Mailing Address - Country:US
Mailing Address - Phone:760-668-4801
Mailing Address - Fax:
Practice Address - Street 1:65896 CAHUILLA AVE
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-3828
Practice Address - Country:US
Practice Address - Phone:760-668-4801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty