Healthcare Provider Details

I. General information

NPI: 1750077558
Provider Name (Legal Business Name): KIMBERLY KUA-MEDEIROS LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 05/13/2023
Certification Date: 05/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92-681 MAKAKILO DR APT 34
KAPOLEI HI
96707-1203
US

IV. Provider business mailing address

92-681 MAKAKILO DR APT 34
KAPOLEI HI
96707-1203
US

V. Phone/Fax

Practice location:
  • Phone: 808-896-6939
  • Fax:
Mailing address:
  • Phone: 808-896-6939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT-832
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: