Provider Demographics
NPI:1275289407
Name:TARYN J IVERS
Entity Type:Organization
Organization Name:TARYN J IVERS
Other - Org Name:LEEWARD COMMUNITY & THERAPY SUPPORTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARYN
Authorized Official - Middle Name:JOY MAI VALDEZ
Authorized Official - Last Name:IVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-429-5731
Mailing Address - Street 1:94-245 LEOKU ST UNIT 970334
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-7014
Mailing Address - Country:US
Mailing Address - Phone:808-466-9111
Mailing Address - Fax:
Practice Address - Street 1:91-1170 MIKOHU ST APT 40C
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-4317
Practice Address - Country:US
Practice Address - Phone:505-429-5731
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-25
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI001525Medicaid
HI003149Medicaid