Healthcare Provider Details

I. General information

NPI: 1790395465
Provider Name (Legal Business Name): TAMARA LASHAE JOHNSON CTRS, MSHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 PATTERSON RD BLDG 110
HONOLULU HI
96819-1522
US

IV. Provider business mailing address

98-707 IHO PL APT 1401
AIEA HI
96701-2525
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-0217
  • Fax:
Mailing address:
  • Phone: 601-467-7705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number70520
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: