Healthcare Provider Details

I. General information

NPI: 1396895900
Provider Name (Legal Business Name): MAVIS A MIZUMOTO PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1268 YOUNG ST STE 200
HONOLULU HI
96814-1801
US

IV. Provider business mailing address

2603 PETER ST
HONOLULU HI
96816-2013
US

V. Phone/Fax

Practice location:
  • Phone: 808-735-2378
  • Fax: 808-597-8183
Mailing address:
  • Phone: 808-735-2378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-481
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: