Provider Demographics
NPI:1558958884
Name:ARICAYOS-VASSALLO, SHANTEL
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:
Last Name:ARICAYOS-VASSALLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-309 APELE
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789
Mailing Address - Country:US
Mailing Address - Phone:808-436-1776
Mailing Address - Fax:
Practice Address - Street 1:70 S KAMEHAMEHA HWY
Practice Address - Street 2:
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786-1856
Practice Address - Country:US
Practice Address - Phone:808-436-1776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI549101YM0800X
HI444103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty