Healthcare Provider Details

I. General information

NPI: 1043745532
Provider Name (Legal Business Name): ELEMENTAL GUIDANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2017
Last Update Date: 04/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 KAMEHAMEHA AVE
HILO HI
96720-2859
US

IV. Provider business mailing address

260 KAMEHAMEHA AVE
HILO HI
96720-2859
US

V. Phone/Fax

Practice location:
  • Phone: 612-644-0737
  • Fax:
Mailing address:
  • Phone: 612-644-0737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberMFT-397
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT-438
License Number StateHI

VIII. Authorized Official

Name: MRS. VISHWANI RAM-SOUZA
Title or Position: CO-OWNER
Credential: MA, LMFT
Phone: 612-644-0737