Healthcare Provider Details

I. General information

NPI: 1972666105
Provider Name (Legal Business Name): HAWKEN SHIELDS PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76-5914 MAMALAHOA HWY
HOLUALOA HI
96725
US

IV. Provider business mailing address

PO BOX 1546
KEALAKEKUA HI
96750-1546
US

V. Phone/Fax

Practice location:
  • Phone: 808-640-0645
  • Fax:
Mailing address:
  • Phone: 808-640-0645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-838
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: