Provider Demographics
NPI:1366458291
Name:DATTOLA, MICHAEL A (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:DATTOLA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 791976
Mailing Address - Street 2:
Mailing Address - City:PAIA
Mailing Address - State:HI
Mailing Address - Zip Code:96779-1976
Mailing Address - Country:US
Mailing Address - Phone:808-707-7219
Mailing Address - Fax:
Practice Address - Street 1:1090 E KUIAHA RD
Practice Address - Street 2:
Practice Address - City:HAIKU
Practice Address - State:HI
Practice Address - Zip Code:96708-5535
Practice Address - Country:US
Practice Address - Phone:808-707-7219
Practice Address - Fax:808-649-2229
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2023-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI34201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI3420OtherSTATE OF HAWAII LICENSE
AK233OtherSTATE OF ALASKA LICENE