MEDICARE: GAIL LYNN TICE PSY.D.

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	103T00000X	Psychologist	PSY 899	HI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1225133481	OTHER	HI	GROUP NPI

General Provider Information

NPI Number	:	1225133481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAIL LYNN TICE PSY.D.

Provider Business Mailing Address
First Line	:	P.O. BOX 161191
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96816
Country	:	US
Telephone Number	:	808-387-5307
Fax Number	:	808-218-7884

Provider Business Practice Location Address
First Line	:	1029 KAPAHULU AVE
Second Line	:	405
City	:	HONOLULU
State	:	HI
Zip	:	96816-1305
Country	:	US
Telephone Number	:	808-387-5307
Fax Number	:	808-218-7884

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

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	01/19/2008

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