=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154820066
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBYN GOODBLATT MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2018
-----------------------------------------------------
Last Update Date | 02/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3620 BALDWIN AVE STE 107
-----------------------------------------------------
City | MAKAWAO
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96768-9500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-498-3589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1075 MAKAWAO AVE UNIT 261
-----------------------------------------------------
City | MAKAWAO
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96768-3012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MHC-484
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------