=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720416464
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIZA M. WACKER, PSY.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2013
-----------------------------------------------------
Last Update Date | 10/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3599 WAIALAE AVENUE
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-927-2587
-----------------------------------------------------
Fax | 866-530-6345
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 25809
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-927-2587
-----------------------------------------------------
Fax | 866-530-6345
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LIZA MALIA WACKER
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 808-927-2587
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY788
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------