Healthcare Provider Details

I. General information

NPI: 1083970545
Provider Name (Legal Business Name): LIFE MASTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 04/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2957 KALAKAUA AVE SUITE 601
HONOLULU HI
96815-4650
US

IV. Provider business mailing address

2957 KALAKAUA AVENUE SUITE 601
HONOLULU HI
96815
US

V. Phone/Fax

Practice location:
  • Phone: 808-737-6277
  • Fax:
Mailing address:
  • Phone: 808-737-6277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number663
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3105
License Number StateHI

VIII. Authorized Official

Name: DR. MITZI GOLD
Title or Position: PSYCHOLOGIST
Credential: PH.D, CLSW, MPH
Phone: 808-737-6277