Healthcare Provider Details

I. General information

NPI: 1356895486
Provider Name (Legal Business Name): KOAN HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 MAKALOA ST SUITE 550
HONOLULU HI
96814-3237
US

IV. Provider business mailing address

1580 MAKALOA ST SUITE 550
HONOLULU HI
96814-3237
US

V. Phone/Fax

Practice location:
  • Phone: 808-469-4505
  • Fax: 808-356-1645
Mailing address:
  • Phone: 808-469-4505
  • Fax: 808-356-1645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMFT 242
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberMFT 242
License Number StateHI

VIII. Authorized Official

Name: IAN WATANABE
Title or Position: PROGRAM MANAGER
Credential: CCM, MFT
Phone: 808-469-4505