Provider Demographics
NPI:1770641789
Name:WACKER, LIZA MALIA (PSYD)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:MALIA
Last Name:WACKER
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:PO BOX 25809
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-0809
Mailing Address - Country:US
Mailing Address - Phone:808-927-2587
Mailing Address - Fax:866-530-6345
Practice Address - Street 1:3599 WAIALAE AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-2776
Practice Address - Country:US
Practice Address - Phone:808-927-2587
Practice Address - Fax:866-530-6345
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY788103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH55235Medicare ID - Type Unspecified