Healthcare Provider Details

I. General information

NPI: 1699594937
Provider Name (Legal Business Name): OLA PONO COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 10/04/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 N UNIVERSITY AVE STE 201
PROVO UT
84601-2867
US

IV. Provider business mailing address

455 N UNIVERSITY AVE STE 201
PROVO UT
84601-2867
US

V. Phone/Fax

Practice location:
  • Phone: 385-446-2466
  • Fax: 385-446-2466
Mailing address:
  • Phone: 385-446-2466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. AUGUSTO DAQUIPA GANCINIA II
Title or Position: OWNER
Credential: PHD
Phone: 385-446-2466