Healthcare Provider Details

I. General information

NPI: 1679608509
Provider Name (Legal Business Name): SHILOH REYNOLDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHILOH REYNOLDS

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 02/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 WAIMANU ST
HONOLULU HI
96813-5248
US

IV. Provider business mailing address

875 WAIMANU ST STE 612
HONOLULU HI
96813-5267
US

V. Phone/Fax

Practice location:
  • Phone: 808-533-3936
  • Fax: 808-791-6198
Mailing address:
  • Phone: 808-791-6713
  • Fax: 808-791-6081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60154399
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60154399
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: