1073867354 NPI number — MS. CRISTEN CLARE CLARK BACHELORS PSYCHOLOGY

Table of content: MS. CRISTEN CLARE CLARK BACHELORS PSYCHOLOGY (NPI 1073867354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073867354 NPI number — MS. CRISTEN CLARE CLARK BACHELORS PSYCHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
CRISTEN
Provider Middle Name:
CLARE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
BACHELORS PSYCHOLOGY
Provider Gender Code:
F

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:
1073867354
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 17424
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96817-0424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-548-1735
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 PIIKOI ST STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96814-3139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-596-8433
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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