=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982062691
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA PETKUS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2016
-----------------------------------------------------
Last Update Date | 03/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1441 KAPIOLANI BLVD STE 1802
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96814-4408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-525-6255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 516 MANANAI PL APT A
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96818-5338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-236-2501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 2207
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------