Provider Demographics
NPI:1275942591
Name:ISLAND PARADISE COUNSELING, LLC
Entity Type:Organization
Organization Name:ISLAND PARADISE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROXY
Authorized Official - Middle Name:ANTOINETTE
Authorized Official - Last Name:MICO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:808-935-0070
Mailing Address - Street 1:PO BOX 10068
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96721
Mailing Address - Country:US
Mailing Address - Phone:808-935-0070
Mailing Address - Fax:808-935-0070
Practice Address - Street 1:162 KINOOLE ST STE 101
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2861
Practice Address - Country:US
Practice Address - Phone:808-935-0070
Practice Address - Fax:808-935-0070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty