Provider Demographics
NPI:1083891469
Name:KA IMI PONO, LLC
Entity Type:Organization
Organization Name:KA IMI PONO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:TICE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:808-387-5307
Mailing Address - Street 1:PO BOX 161191
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-0925
Mailing Address - Country:US
Mailing Address - Phone:808-387-5307
Mailing Address - Fax:808-218-7884
Practice Address - Street 1:1029 KAPAHULU AVE STE 405
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-1332
Practice Address - Country:US
Practice Address - Phone:808-387-5307
Practice Address - Fax:808-218-7884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI899103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1225133481OtherPERSONAL NPI