Healthcare Provider Details

I. General information

NPI: 1366458291
Provider Name (Legal Business Name): MICHAEL A DATTOLA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 06/10/2023
Certification Date: 06/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 E KUIAHA RD
HAIKU HI
96708-5535
US

IV. Provider business mailing address

PO BOX 791976
PAIA HI
96779-1976
US

V. Phone/Fax

Practice location:
  • Phone: 808-707-7219
  • Fax: 808-649-2229
Mailing address:
  • Phone: 808-707-7219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3420
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: