Healthcare Provider Details

I. General information

NPI: 1649464355
Provider Name (Legal Business Name): BEARDEN PSYCHOLOGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 AUPUNI ST SUITE 1014 A-2
HILO HI
96720-4246
US

IV. Provider business mailing address

101 AUPUNI ST SUITE 1014 A-2
HILO HI
96720-4246
US

V. Phone/Fax

Practice location:
  • Phone: 808-935-2605
  • Fax: 808-935-2650
Mailing address:
  • Phone: 808-935-2605
  • Fax: 808-935-2650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberPSY 888
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberPSY 888
License Number StateHI

VIII. Authorized Official

Name: DR. THOMAS STENNIS BEARDEN
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 808-935-2605