Provider Demographics
NPI:1114160140
Name:MORENO, CONRAD WK (PHD)
Entity Type:Individual
Prefix:MR
First Name:CONRAD
Middle Name:WK
Last Name:MORENO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 OHUA AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-6612
Mailing Address - Country:US
Mailing Address - Phone:808-791-9355
Mailing Address - Fax:808-697-6849
Practice Address - Street 1:277 OHUA AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96815-3643
Practice Address - Country:US
Practice Address - Phone:808-922-4787
Practice Address - Fax:808-922-4950
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1064103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist