Healthcare Provider Details

I. General information

NPI: 1356515498
Provider Name (Legal Business Name): LISA KT JICHA LCSW, CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date: 01/18/2011
Reactivation Date: 08/24/2017

III. Provider practice location address

100 KAHELU AVE STE 232
MILILANI HI
96789-3962
US

IV. Provider business mailing address

PO BOX 893542
MILILANI HI
96789-0542
US

V. Phone/Fax

Practice location:
  • Phone: 808-625-7448
  • Fax:
Mailing address:
  • Phone: 808-783-7860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3246
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: