Healthcare Provider Details

I. General information

NPI: 1588091219
Provider Name (Legal Business Name): ILEA BAIN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2013
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53-3925 AKONI PULE HIGHWAY
KAPAAU HI
96755
US

IV. Provider business mailing address

45-549 PLUMERIA ST
HONOKAA HI
96727-6902
US

V. Phone/Fax

Practice location:
  • Phone: 808-889-6236
  • Fax: 808-889-0107
Mailing address:
  • Phone: 808-775-7204
  • Fax: 808-775-9404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2763
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: