Healthcare Provider Details

I. General information

NPI: 1194806315
Provider Name (Legal Business Name): TANYA J. D'AVANZO PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 QUEEN ST STE 703
HONOLULU HI
96813-4718
US

IV. Provider business mailing address

1123 KOOHOO PL
KAILUA HI
96734-3276
US

V. Phone/Fax

Practice location:
  • Phone: 808-521-3761
  • Fax: 800-491-4155
Mailing address:
  • Phone: 808-566-3761
  • Fax: 808-566-3859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY635
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY635
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: