Provider Demographics
NPI:1215218805
Name:BLUE, TANECIA MARSHIA (PHD)
Entity Type:Individual
Prefix:
First Name:TANECIA
Middle Name:MARSHIA
Last Name:BLUE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-1522
Mailing Address - Country:US
Mailing Address - Phone:808-433-0031
Mailing Address - Fax:
Practice Address - Street 1:459 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-1522
Practice Address - Country:US
Practice Address - Phone:808-433-0045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001222103T00000X
103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth