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General NPI Number Information
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NPI Number | 1699849422
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Entity Type | Organization
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Legal Business Name | PHOENIX CENTER INC
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Dates
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Enumeration Date | 11/20/2006
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Last Update Date | 12/12/2023
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Provider Practice Location Address
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Address Line | 169 PUUEO ST
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City | HILO
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State | HI
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Zip | 96720-2432
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Country | US
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Telephone | 808-934-7355
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Fax | 808-935-3209
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Provider Business Mailing Address
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Address Line | PO BOX 10840
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City | HILO
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State | HI
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Zip | 96721-5840
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Country | US
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Telephone | 808-934-7355
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Fax | 808-935-3209
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Authorized Official
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Title or Position | PRESIDENT
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Name | SHELLEY E. HAM
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Credential | M.D.
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Telephone | 808-934-7355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW3200
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License Number State | HI
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | MD8985
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License Number State | HI
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