Provider Demographics
NPI:1407283732
Name:ISLAND THERAPEUTIC SPECIALISTS LLC
Entity Type:Organization
Organization Name:ISLAND THERAPEUTIC SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR OF THERAPEUTIC SERVICE
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:808-238-9565
Mailing Address - Street 1:PO BOX 928
Mailing Address - Street 2:
Mailing Address - City:CAPTAIN COOK
Mailing Address - State:HI
Mailing Address - Zip Code:96704-0928
Mailing Address - Country:US
Mailing Address - Phone:808-987-2451
Mailing Address - Fax:
Practice Address - Street 1:81-6587 MAMALAHOA HWY
Practice Address - Street 2:SUITE C-203
Practice Address - City:KEALAKEKUA
Practice Address - State:HI
Practice Address - Zip Code:96750
Practice Address - Country:US
Practice Address - Phone:808-987-2451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-01
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1663-12101YA0400X
HI1535-10101YA0400X
HI39041041C0700X
HI1055235Z00000X
HI1286235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty