Healthcare Provider Details

I. General information

NPI: 1376202218
Provider Name (Legal Business Name): KUALOLI COUNSELING & PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 12/08/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5476 KOLOA ROAD, 2F
KOLOA HI
96756-9675
US

IV. Provider business mailing address

PO BOX 1075
KOLOA HI
96756-1075
US

V. Phone/Fax

Practice location:
  • Phone: 808-639-7255
  • Fax:
Mailing address:
  • Phone: 808-639-7255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: SHANTI KAY MANZANO
Title or Position: OWNER/PROVIDER
Credential: LCSW
Phone: 808-639-7255