Healthcare Provider Details

I. General information

NPI: 1053507699
Provider Name (Legal Business Name): DESIREE HENRY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 11/28/2025
Certification Date: 11/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1164 W KUIAHA RD
HAIKU HI
96708-5500
US

IV. Provider business mailing address

PO BOX 791435
PAIA HI
96779-1435
US

V. Phone/Fax

Practice location:
  • Phone: 860-964-8692
  • Fax:
Mailing address:
  • Phone: 860-964-8692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-3784
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: