MEDICARE: DISA ESPIRITU LCSW

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	1041C0700X	Clinical Social Worker	LCSW-4473	HI

General Provider Information

NPI Number	:	1821384009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DISA ESPIRITU LCSW

Provider Business Mailing Address
First Line	:	PO BOX
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96828
Country	:	US
Telephone Number	:	702-354-5996
Fax Number	:

Provider Business Practice Location Address
First Line	:	2533 LA FORTUNA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-5436
Country	:	US
Telephone Number	:	702-354-5996
Fax Number	:

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

Provider Enumeration Date	:	06/25/2011
Last Update Date	:	04/24/2020

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