Provider Demographics
NPI:1134177785
Name:KANESHIRO, LISA (PSY)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KANESHIRO
Suffix:
Gender:F
Credentials:PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 KALANIANAOLE AVE
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-4740
Mailing Address - Country:US
Mailing Address - Phone:808-969-1427
Mailing Address - Fax:808-961-4795
Practice Address - Street 1:15-2866 PAHOA VILLIAGE ROAD
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778
Practice Address - Country:US
Practice Address - Phone:808-965-9711
Practice Address - Fax:808-965-6240
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY848103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral