=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770641789
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LIZA MALIA WACKER PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2006
-----------------------------------------------------
Last Update Date | 11/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3599 WAIALAE AVE
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96816-2776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-927-2587
-----------------------------------------------------
Fax | 866-530-6345
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 25809
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96825-0809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-927-2587
-----------------------------------------------------
Fax | 866-530-6345
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY788
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------