MEDICARE: DR. GEORGE BERGHOLZ 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1538317250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE BERGHOLZ PSY. D.

Provider Business Mailing Address
First Line	:	60 N NIMITZ HWY
Second Line	:	APT 1906
City	:	HONOLULU
State	:	HI
Zip	:	96817-5338
Country	:	US
Telephone Number	:	808-306-7708
Fax Number	:

Provider Business Practice Location Address
First Line	:	60 N NIMITZ HWY
Second Line	:	APT 1906
City	:	HONOLULU
State	:	HI
Zip	:	96817-5338
Country	:	US
Telephone Number	:	808-306-7708
Fax Number	:

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

Provider Enumeration Date	:	09/05/2008
Last Update Date	:	09/05/2008

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