Healthcare Provider Details

I. General information

NPI: 1922408020
Provider Name (Legal Business Name): KOKUA SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1803 N KING ST
HONOLULU HI
96819-3451
US

IV. Provider business mailing address

PO BOX 17870
HONOLULU HI
96817-0870
US

V. Phone/Fax

Practice location:
  • Phone: 808-847-4227
  • Fax: 808-842-0044
Mailing address:
  • Phone: 808-847-4227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10694948
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10694948
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10694948
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number10694948
License Number StateHI
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10694948
License Number StateHI
# 6
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number10694948
License Number StateHI
# 7
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number10694948
License Number StateHI
# 8
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number10694948
License Number StateHI

VIII. Authorized Official

Name: TRISTYN HAXTON
Title or Position: PRESIDENT
Credential: MSCP,CSAC, SAP
Phone: 808-847-5777