Healthcare Provider Details

I. General information

NPI: 1104432582
Provider Name (Legal Business Name): CHARLES RIVERA BSW, CSAC, CCJP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 PATTERSON RD # MHS-116
HONOLULU HI
96819-1522
US

IV. Provider business mailing address

459 PATTERSON RD # MHS-116
HONOLULU HI
96819-1522
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-3010
  • Fax: 808-433-0395
Mailing address:
  • Phone: 808-433-3010
  • Fax: 808-433-0395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: