Healthcare Provider Details

I. General information

NPI: 1619112877
Provider Name (Legal Business Name): BLOSSOM IWALANI FONOIMOANA PSYD, MSW, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2008
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 MAUNALOA HWY #C
KAUNAKAKAI HI
96748-0130
US

IV. Provider business mailing address

56-660 KAMEHAMEHA HWY
KAHUKU HI
96731-2210
US

V. Phone/Fax

Practice location:
  • Phone: 808-560-3653
  • Fax: 808-560-3385
Mailing address:
  • Phone: 808-293-7555
  • Fax: 808-293-7196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLSW 1557
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY-1524
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-3658
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: