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General NPI Number Information
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NPI Number | 1902115082
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Entity Type | Organization
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Legal Business Name | MARK D BREITHAUPT PHD INC
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Dates
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Enumeration Date | 10/06/2010
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Last Update Date | 05/19/2025
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Provider Practice Location Address
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Address Line | 2200 MAIN ST
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City | WAILUKU
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State | HI
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Zip | 96793-1681
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Country | US
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Telephone | 808-205-8403
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2632
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City | WAILUKU
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State | HI
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Zip | 96793-7632
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Country | US
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Telephone | 808-205-8403
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL PSYCHOLOGIST
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Name | MARK DOUGLAS BREITHAUPT
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Credential | PHD
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Telephone | 808-205-8403
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY499
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License Number State | HI
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