Provider Demographics
NPI:1629416581
Name:EKSTROM, JUDITH MARIE (LMHC)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:MARIE
Last Name:EKSTROM
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:MARIE
Other - Last Name:SPAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:HC 2 BOX 6410
Mailing Address - Street 2:
Mailing Address - City:KEAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96749-9305
Mailing Address - Country:US
Mailing Address - Phone:808-987-4321
Mailing Address - Fax:
Practice Address - Street 1:15-3039 PAHOA VILLAGE RD
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778-9998
Practice Address - Country:US
Practice Address - Phone:808-987-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI299101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health