Provider Demographics
NPI:1225133481
Name:TICE, GAIL LYNN (PSYD)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:LYNN
Last Name:TICE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 161191
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816
Mailing Address - Country:US
Mailing Address - Phone:808-387-5307
Mailing Address - Fax:808-218-7884
Practice Address - Street 1:1029 KAPAHULU AVE
Practice Address - Street 2:405
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-1305
Practice Address - Country:US
Practice Address - Phone:808-387-5307
Practice Address - Fax:808-218-7884
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2008-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY 899103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1225133481OtherGROUP NPI
HI101369Medicare ID - Type Unspecified