Provider Demographics
NPI:1114200052
Name:WANG, TIA
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 N CANE ST
Mailing Address - Street 2:STE A
Mailing Address - City:WAHIAWA
Mailing Address - State:HI
Mailing Address - Zip Code:96786-2130
Mailing Address - Country:US
Mailing Address - Phone:808-258-9362
Mailing Address - Fax:
Practice Address - Street 1:319 N CANE ST
Practice Address - Street 2:STE A
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786-2130
Practice Address - Country:US
Practice Address - Phone:808-258-9362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-1281103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical