=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740508688
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS SZUBIAK MSW, LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2010
-----------------------------------------------------
Last Update Date | 05/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64-1035 MAMALAHO HWY SUITE O
-----------------------------------------------------
City | KAMUELA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96743-8440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-895-7679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 68-1125 N KANIKU DR APT 1106
-----------------------------------------------------
City | KAMUELA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96743-7722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-895-7679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 3637
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 73-069952
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 11892
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------