Healthcare Provider Details

I. General information

NPI: 1134177785
Provider Name (Legal Business Name): LISA KANESHIRO PSY
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15-2866 PAHOA VILLIAGE ROAD
PAHOA HI
96778
US

IV. Provider business mailing address

311 KALANIANAOLE AVE
HILO HI
96720-4740
US

V. Phone/Fax

Practice location:
  • Phone: 808-965-9711
  • Fax: 808-965-6240
Mailing address:
  • Phone: 808-969-1427
  • Fax: 808-961-4795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY848
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: