=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558802017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEAP OF FAITH COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2017
-----------------------------------------------------
Last Update Date | 03/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2637 KUILEI ST APT A104
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96826-3288
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-635-3464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2637 KUILEI ST APT A104
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96826-3288
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-635-3464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MR. NATHANIEL BERALAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 808-635-3464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 393
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 491
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------