Provider Demographics
NPI:1659736866
Name:BALE, DOMINIQUE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:
Last Name:BALE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98-1268 KAAHUMANU ST
Mailing Address - Street 2:STE 202
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-3257
Mailing Address - Country:US
Mailing Address - Phone:808-955-4775
Mailing Address - Fax:808-955-3130
Practice Address - Street 1:98-1268 KAAHUMANU ST
Practice Address - Street 2:STE 202
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-3257
Practice Address - Country:US
Practice Address - Phone:808-955-4775
Practice Address - Fax:808-955-3130
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-1575103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical