1366458291 NPI number — MR. MICHAEL A DATTOLA LCSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366458291 NPI number — MR. MICHAEL A DATTOLA LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DATTOLA
Provider First Name:
MICHAEL
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

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:
1366458291
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 791976
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAIA
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96779-1976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-707-7219
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1090 E KUIAHA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAIKU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96708-5535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-707-7219
Provider Business Practice Location Address Fax Number:
808-649-2229
Provider Enumeration Date:
07/31/2006

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: 1041C0700X , with the licence number:  3420 , 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: 3420 . This is a "STATE OF HAWAII LICENSE" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".




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