Healthcare Provider Details

I. General information

NPI: 1538794201
Provider Name (Legal Business Name): IKE LOA THERAPEUTIC SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 LILIHA ST STE 406
HONOLULU HI
96817-3564
US

IV. Provider business mailing address

1520 LILIHA ST STE 406
HONOLULU HI
96817-3564
US

V. Phone/Fax

Practice location:
  • Phone: 714-584-9889
  • Fax: 808-600-3754
Mailing address:
  • Phone: 714-584-9889
  • Fax: 808-600-3754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MAILA KANEAIAKALA
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 808-220-3665