Provider Demographics
NPI:1073765764
Name:CARLSON BROFF, ANGELA (MSCP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:CARLSON BROFF
Suffix:
Gender:F
Credentials:MSCP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 HEKILI ST STE A406
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2800
Mailing Address - Country:US
Mailing Address - Phone:808-489-3548
Mailing Address - Fax:
Practice Address - Street 1:111 HEKILI ST STE A
Practice Address - Street 2:#406
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734
Practice Address - Country:US
Practice Address - Phone:808-489-3548
Practice Address - Fax:808-443-0708
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
HIBA-24103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor