Healthcare Provider Details

I. General information

NPI: 1205216959
Provider Name (Legal Business Name): DSM THERAPEUTIC AND WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91-1100 PAAOLOULU WAY
KAPOLEI HI
96707-3102
US

IV. Provider business mailing address

92-7045 KAHEA ST
KAPOLEI HI
96707-2302
US

V. Phone/Fax

Practice location:
  • Phone: 808-387-3922
  • Fax: 808-672-0104
Mailing address:
  • Phone: 808-387-3922
  • Fax: 808-672-0104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateHI

VIII. Authorized Official

Name: DANELLE S MEDEIROS
Title or Position: MEMBER MANAGER
Credential: MSCP
Phone: 808-387-3922