Provider Demographics
NPI:1306201629
Name:HEAVENLY STAR LLC
Entity Type:Organization
Organization Name:HEAVENLY STAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:RENA MAE
Authorized Official - Middle Name:NALANI
Authorized Official - Last Name:TAKUSHI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:808-781-7984
Mailing Address - Street 1:99-124 KOHOMUA ST
Mailing Address - Street 2:15C
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-3876
Mailing Address - Country:US
Mailing Address - Phone:808-781-7984
Mailing Address - Fax:
Practice Address - Street 1:99-124 KOHOMUA ST
Practice Address - Street 2:15C
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-3876
Practice Address - Country:US
Practice Address - Phone:808-781-7984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI40541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty