1194964353 NPI number — PSYCHOLOGICAL SERVICE CENTER, LLC

Table of content: (NPI 1194964353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194964353 NPI number — PSYCHOLOGICAL SERVICE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHOLOGICAL SERVICE CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194964353
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
126 PENI PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KULA
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96790-8772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-280-9457
Provider Business Mailing Address Fax Number:
808-572-0311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1135 MAKAWAO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAKAWAO
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96768-7403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-280-9457
Provider Business Practice Location Address Fax Number:
808-572-0311
Provider Enumeration Date:
02/11/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LANE
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF PSYCHOLOGIST
Authorized Official Telephone Number:
808-280-9457

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A0258473 . This is a "HMSA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 57950002 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 548195324 . This is a "UNIVERSITY HEALTH ALLIANCE" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 57950000-1 . This is a "ALOHA CARE QUEST" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".