Healthcare Provider Details

I. General information

NPI: 1720909310
Provider Name (Legal Business Name): LAUREN ELISE SHUMAKER BRADLEY
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: ELLIS SHUMAKER BRADLEY

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99-080 KAUHALE ST # C120
AIEA HI
96701-4116
US

IV. Provider business mailing address

99-080 KAUHALE ST # C120
AIEA HI
96701-4116
US

V. Phone/Fax

Practice location:
  • Phone: 808-953-4682
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHCP-35
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: