=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306575915
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELANIE KIM VAN DER TUIN LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2022
-----------------------------------------------------
Last Update Date | 06/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1822 KEEAUMOKU ST
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96822-3001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-276-4160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4198 KILAUEA AVE
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96816-4452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-276-4160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT-763
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------