Healthcare Provider Details

I. General information

NPI: 1972803294
Provider Name (Legal Business Name): ANGELA MARTINEZ JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74-4997 MAMALAHOA HWY
HOLUALOA HI
96725-9605
US

IV. Provider business mailing address

74-4997 MAMALAHOA HWY
HOLUALOA HI
96725-9605
US

V. Phone/Fax

Practice location:
  • Phone: 808-798-1373
  • Fax:
Mailing address:
  • Phone: 808-798-1373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC507
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMHC507
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: