Provider Demographics
NPI:1003413097
Name:PROVIDENCE LIVING LLC
Entity Type:Organization
Organization Name:PROVIDENCE LIVING LLC
Other - Org Name:PROVIDENCE TREATMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:HERAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCSW
Authorized Official - Phone:808-445-6780
Mailing Address - Street 1:1188 BISHOP ST STE 1008
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-3304
Mailing Address - Country:US
Mailing Address - Phone:808-445-6780
Mailing Address - Fax:888-373-9844
Practice Address - Street 1:1188 BISHOP ST STE 1008
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-3304
Practice Address - Country:US
Practice Address - Phone:808-445-6780
Practice Address - Fax:888-373-9844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-03
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility