MEDICARE: DR. DOMINIQUE BALE 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	103TC0700X	Clinical Psychologist	PSY-1575	HI

General Provider Information

NPI Number	:	1659736866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOMINIQUE BALE PSY.D.

Provider Business Mailing Address
First Line	:	98-1268 KAAHUMANU ST
Second Line	:	STE 202
City	:	PEARL CITY
State	:	HI
Zip	:	96782-3257
Country	:	US
Telephone Number	:	808-955-4775
Fax Number	:	808-955-3130

Provider Business Practice Location Address
First Line	:	98-1268 KAAHUMANU ST
Second Line	:	STE 202
City	:	PEARL CITY
State	:	HI
Zip	:	96782-3257
Country	:	US
Telephone Number	:	808-955-4775
Fax Number	:	808-955-3130

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

Provider Enumeration Date	:	12/15/2015
Last Update Date	:	12/15/2015

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