Healthcare Provider Details

I. General information

NPI: 1396404877
Provider Name (Legal Business Name): BEACON OF LASTING CHANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2021
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

438 HOBRON LN STE 311
HONOLULU HI
96815-1229
US

IV. Provider business mailing address

5984 GANNET AVE
EWA BEACH HI
96706-3239
US

V. Phone/Fax

Practice location:
  • Phone: 808-600-1132
  • Fax:
Mailing address:
  • Phone: 808-600-1132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. MAITA MARKS
Title or Position: MANAGER
Credential: LMFT
Phone: 808-600-1132