Healthcare Provider Details

I. General information

NPI: 1376311415
Provider Name (Legal Business Name): PACIFIC COUNSELING GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 S KIHEI RD STE 200
KIHEI HI
96753-8145
US

IV. Provider business mailing address

PO BOX 1492
MAKAWAO HI
96768-1492
US

V. Phone/Fax

Practice location:
  • Phone: 808-866-8753
  • Fax:
Mailing address:
  • Phone: 808-281-6284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DAVID J WITTENBERG
Title or Position: MEMBER - MANAGER
Credential: PSYD
Phone: 808-281-6284