Healthcare Provider Details

I. General information

NPI: 1740503929
Provider Name (Legal Business Name): CHARLENE S MERRITT CSCAC, ICADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 WAIANUENUE AVE STE 202
HILO HI
96720-2474
US

IV. Provider business mailing address

56 WAIANUENUE AVE STE 202
HILO HI
96720-2474
US

V. Phone/Fax

Practice location:
  • Phone: 808-935-4412
  • Fax:
Mailing address:
  • Phone: 808-935-4412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1318-07
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: