=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265294649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREY HALLIDAY FENTON LCSW, CSAC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2024
-----------------------------------------------------
Last Update Date | 01/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 438 HOBRON LN STE 315
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96815-1229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-542-1389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3081 PATY DR APT H
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96822-1448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-542-1389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. TREY HALLIDAY FENTON
-----------------------------------------------------
Credential | LCSW, CSAC
-----------------------------------------------------
Telephone | 808-542-1389
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------