Healthcare Provider Details

I. General information

NPI: 1700051117
Provider Name (Legal Business Name): HEIDEMARIE KOOP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81-6161 D ROAD
CAPTAIN COOK HI
96704
US

IV. Provider business mailing address

75-5744 ALII DR 237
KAILUA KONA HI
96740-1740
US

V. Phone/Fax

Practice location:
  • Phone: 808-987-2296
  • Fax:
Mailing address:
  • Phone: 808-987-2296
  • Fax: 877-585-5099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW - 3268
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: