Healthcare Provider Details

I. General information

NPI: 1801078993
Provider Name (Legal Business Name): PRIMA MAY MANGONON MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
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

9330 59TH AVE SW
LAKEWOOD WA
98499-2858
US

V. Phone/Fax

Practice location:
  • Phone: 808-585-1424
  • Fax:
Mailing address:
  • Phone: 253-620-5095
  • 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: