Healthcare Provider Details

I. General information

NPI: 1376947119
Provider Name (Legal Business Name): CHANEL EVALANI KEALOHA PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHILDRENS WAY # MC5042
SAN DIEGO CA
92123-4223
US

IV. Provider business mailing address

564 SOUTH ST
HONOLULU HI
96813-5013
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-7453
  • Fax: 858-966-8011
Mailing address:
  • Phone: 808-591-1173
  • Fax: 808-591-1174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number31266
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY 1487
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: