=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144729989
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BY THE WAVES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2018
-----------------------------------------------------
Last Update Date | 02/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 97 AIKAHI LOOP
-----------------------------------------------------
City | KAILUA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96734-1674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-347-4626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 97 AIKAHI LOOP
-----------------------------------------------------
City | KAILUA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96734-1674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-347-4626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ PSYCHOLOGIST
-----------------------------------------------------
Name | DR. MELBA C STETZ
-----------------------------------------------------
Credential | PH.D., BCN, BCB
-----------------------------------------------------
Telephone | 808-347-4626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY-I
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------