=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730781394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SWEET MANOA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2020
-----------------------------------------------------
Last Update Date | 11/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 QUEEN ST STE 100
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96814-4130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-913-8840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 909 KAPIOLANI BLVD APT 1603
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96814-2139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-913-8840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | HYUNGBUM KANG
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 808-913-8840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------