Provider Demographics
NPI:1659753622
Name:MEDEIROS, DANELLE
Entity Type:Individual
Prefix:
First Name:DANELLE
Middle Name:
Last Name:MEDEIROS
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 1:92-7045 KAHEA ST
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2302
Mailing Address - Country:US
Mailing Address - Phone:808-387-3922
Mailing Address - Fax:808-672-0104
Practice Address - Street 1:1001 KAMOKILA BLVD 203
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2014
Practice Address - Country:US
Practice Address - Phone:808-387-3045
Practice Address - Fax:808-672-0104
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMHC123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health