MEDICARE: LISA KANESHIRO PSY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TB0200X	Cognitive & Behavioral Psychologist	PSY848	HI

General Provider Information

NPI Number	:	1134177785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA KANESHIRO PSY

Provider Business Mailing Address
First Line	:	311 KALANIANAOLE AVE
Second Line	:
City	:	HILO
State	:	HI
Zip	:	96720-4740
Country	:	US
Telephone Number	:	808-969-1427
Fax Number	:	808-961-4795

Provider Business Practice Location Address
First Line	:	15-2866 PAHOA VILLIAGE ROAD
Second Line	:
City	:	PAHOA
State	:	HI
Zip	:	96778
Country	:	US
Telephone Number	:	808-965-9711
Fax Number	:	808-965-6240

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	07/08/2007

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