Provider Demographics
NPI:1376520890
Name:MERSEREAU, EDWARD ATHUR (LCSW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:ATHUR
Last Name:MERSEREAU
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 1:970 N KALAHEO AVE
Mailing Address - Street 2:SUITE A310-B
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-1801
Mailing Address - Country:US
Mailing Address - Phone:808-375-3338
Mailing Address - Fax:
Practice Address - Street 1:970 N KALAHEO AVE
Practice Address - Street 2:SUITE A310-B
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-1801
Practice Address - Country:US
Practice Address - Phone:808-375-3338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HICSAC -979-99101YA0400X
HILCSW-34671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicare UPIN