1417042227 NPI number — MR. GLENN A KONDO DCSW LCSW CSAC

Table of content: MR. GLENN A KONDO DCSW LCSW CSAC (NPI 1417042227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417042227 NPI number — MR. GLENN A KONDO DCSW LCSW CSAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONDO
Provider First Name:
GLENN
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DCSW LCSW CSAC
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:
1417042227
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10621
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILO
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96721-1062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-935-5687
Provider Business Mailing Address Fax Number:
808-935-8873

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
688 KINOOLE ST
Provider Second Line Business Practice Location Address:
STE 119B
Provider Business Practice Location Address City Name:
HILO
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-935-5687
Provider Business Practice Location Address Fax Number:
808-935-8873
Provider Enumeration Date:
10/04/2006

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: 101YA0400X , with the licence number:  90193 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LCSW3070 , 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: A02141262 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".




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