=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225521909
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARISSA AWAPUHI CORDEIRA PSY.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2018
-----------------------------------------------------
Last Update Date | 06/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 66-590 KAMEHAMEHA HWY STE 2G
-----------------------------------------------------
City | HALEIWA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96712-1484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-721-7481
-----------------------------------------------------
Fax | 808-888-0550
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 94-546 KUPUOHI ST APT 202
-----------------------------------------------------
City | WAIPAHU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96797-5316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-721-7481
-----------------------------------------------------
Fax | 808-688-9868
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY-1713
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------