Healthcare Provider Details

I. General information

NPI: 1619201738
Provider Name (Legal Business Name): DWAINE WILLIAM TAIT MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MOHOULI ST
HILO HI
96720-4181
US

IV. Provider business mailing address

77 MOHOULI ST
HILO HI
96720-4181
US

V. Phone/Fax

Practice location:
  • Phone: 808-961-5166
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: