Healthcare Provider Details

I. General information

NPI: 1013414770
Provider Name (Legal Business Name): CROSSROADS BEHAVIORAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91-1010 SHANGRILA ST STE 105
KAPOLEI HI
96707-2176
US

IV. Provider business mailing address

PO BOX 701089
KAPOLEI HI
96709-1089
US

V. Phone/Fax

Practice location:
  • Phone: 808-377-4300
  • Fax:
Mailing address:
  • Phone: 808-294-3493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY809
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT E JACKSON
Title or Position: PRESIDENT
Credential: PHD
Phone: 808-294-3493