=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932648474
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DORENE TOUTANT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2017
-----------------------------------------------------
Last Update Date | 02/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 KAUKINI LOOP
-----------------------------------------------------
City | WAILUKU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96793-5755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-755-8726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1704 WILI PA LOOP 272
-----------------------------------------------------
City | WAILUKU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96793-1240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-755-8726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DORENE CATHERINE TOUTANT
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 626-755-8726
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 4199
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------