Healthcare Provider Details

I. General information

NPI: 1740882984
Provider Name (Legal Business Name): KAYLEEN SUR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2020
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 ALA MOANA BLVD STE 1
HONOLULU HI
96814-4262
US

IV. Provider business mailing address

3533 ALIAMANU ST
HONOLULU HI
96818-2845
US

V. Phone/Fax

Practice location:
  • Phone: 808-585-1424
  • Fax: 808-585-0379
Mailing address:
  • Phone: 808-561-5137
  • Fax:

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: