Healthcare Provider Details

I. General information

NPI: 1740319177
Provider Name (Legal Business Name): SUSAN C SICKORA CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 N KALAHEO AVE SUITE A102
KAILUA HI
96734-1801
US

IV. Provider business mailing address

820 MILILANI ST STE 702A
HONOLULU HI
96813-2918
US

V. Phone/Fax

Practice location:
  • Phone: 808-254-6484
  • Fax: 808-254-6427
Mailing address:
  • Phone: 808-523-9363
  • Fax: 808-523-9418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRN26584
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: