Healthcare Provider Details

I. General information

NPI: 1073642526
Provider Name (Legal Business Name): KEITH DAVIDSON WHITAKER LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 1 BOX 5412
KEAAU HI
96749-9530
US

IV. Provider business mailing address

HC 1 BOX 5412
KEAAU HI
96749-9530
US

V. Phone/Fax

Practice location:
  • Phone: 808-982-6503
  • Fax: 808-982-6298
Mailing address:
  • Phone: 808-982-6503
  • Fax: 808-982-6298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number26
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: