Healthcare Provider Details

I. General information

NPI: 1982574687
Provider Name (Legal Business Name): AUDREY AKIKO SUGIMOTO
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2025
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 HINA AVE
KAHULUI HI
96732-2717
US

IV. Provider business mailing address

2618 SAN JACINTO ST
SIMI VALLEY CA
93063-2395
US

V. Phone/Fax

Practice location:
  • Phone: 808-727-4700
  • Fax:
Mailing address:
  • Phone: 805-657-1756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP101710
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP.LL.70030853
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number252361
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number38460
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP-2559
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: