=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891591012
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAWAI'I DCR HEALTHCARE DIVISION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2025
-----------------------------------------------------
Last Update Date | 02/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 99-902 MOANALUA RD
-----------------------------------------------------
City | AIEA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96701-5605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-485-1897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1177 ALAKEA ST STE 602
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96813-2824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-587-3375
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIVISION ADMINISTRATOR
-----------------------------------------------------
Name | ROMEY GLIDEWELL
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 85-878-3375
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2083A0300X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------