Provider Demographics
NPI:1346643236
Name:THE LAVENDER CLINIC
Entity Type:Organization
Organization Name:THE LAVENDER CLINIC
Other - Org Name:THE LAVENDER CENTER & CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKHAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-744-2543
Mailing Address - Street 1:1481 S KING ST STE 422
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-2600
Mailing Address - Country:US
Mailing Address - Phone:808-744-2543
Mailing Address - Fax:866-451-4608
Practice Address - Street 1:1481 S KING ST STE 422
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-2600
Practice Address - Country:US
Practice Address - Phone:808-744-2543
Practice Address - Fax:866-451-4608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI835481Medicaid