Provider Demographics
NPI:1417042227
Name:KONDO, GLENN A (DCSW LCSW CSAC)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:A
Last Name:KONDO
Suffix:
Gender:M
Credentials:DCSW LCSW CSAC
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 10621
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96721-1062
Mailing Address - Country:US
Mailing Address - Phone:808-935-5687
Mailing Address - Fax:808-935-8873
Practice Address - Street 1:688 KINOOLE ST
Practice Address - Street 2:STE 119B
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720
Practice Address - Country:US
Practice Address - Phone:808-935-5687
Practice Address - Fax:808-935-8873
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI90193101YA0400X
HILCSW30701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIA02141262Medicaid
S74254Medicare UPIN
H51515Medicare ID - Type Unspecified