Healthcare Provider Details

I. General information

NPI: 1740342419
Provider Name (Legal Business Name): GRETCHEN S. WIGTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79-1020 HAUKAPILA ST
KEALAKEKUA HI
96750-7922
US

IV. Provider business mailing address

74-5037 HANAHANAI LOOP
KAILUA KONA HI
96740-1538
US

V. Phone/Fax

Practice location:
  • Phone: 808-322-4818
  • Fax: 808-322-4817
Mailing address:
  • Phone: 808-322-4818
  • Fax: 808-322-4817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW - 3229
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: