Provider Demographics
NPI:1619112877
Name:FONOIMOANA, BLOSSOM IWALANI (PSYD, MSW, LSW)
Entity Type:Individual
Prefix:DR
First Name:BLOSSOM
Middle Name:IWALANI
Last Name:FONOIMOANA
Suffix:
Gender:F
Credentials:PSYD, MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56-660 KAMEHAMEHA HWY
Mailing Address - Street 2:
Mailing Address - City:KAHUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96731-2210
Mailing Address - Country:US
Mailing Address - Phone:808-293-7555
Mailing Address - Fax:808-293-7196
Practice Address - Street 1:604 MAUNALOA HWY
Practice Address - Street 2:#C
Practice Address - City:KAUNAKAKAI
Practice Address - State:HI
Practice Address - Zip Code:96748-0130
Practice Address - Country:US
Practice Address - Phone:808-560-3653
Practice Address - Fax:808-560-3385
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILSW 1557104100000X
HIPSY-1524103T00000X
HILCSW-36581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical