Healthcare Provider Details

I. General information

NPI: 1922921717
Provider Name (Legal Business Name): NEZAM ARDALAN MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 S WAKEA AVE STE 201
KAHULUI HI
96732-1385
US

IV. Provider business mailing address

192 KAPUAHI ST
MAKAWAO HI
96768-8007
US

V. Phone/Fax

Practice location:
  • Phone: 808-249-2121
  • Fax:
Mailing address:
  • Phone: 646-244-0652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHCP-20
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: