Healthcare Provider Details

I. General information

NPI: 1871001636
Provider Name (Legal Business Name): KELLY H TAKASAWA, PSYD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2018
Last Update Date: 01/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 KAPIOLANI BLVD STE 211
HONOLULU HI
96814-3506
US

IV. Provider business mailing address

1221 KAPIOLANI BLVD STE 211
HONOLULU HI
96814-3506
US

V. Phone/Fax

Practice location:
  • Phone: 808-538-7793
  • Fax:
Mailing address:
  • Phone: 808-538-7793
  • Fax: 808-538-7799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPSY-1215
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-1215
License Number StateHI

VIII. Authorized Official

Name: KELLY TAKASAWA
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PSYD
Phone: 808-538-7793