Provider Demographics
NPI:1134436041
Name:FUKUMOTO, MICHELLE K (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:K
Last Name:FUKUMOTO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 283249
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96828
Mailing Address - Country:US
Mailing Address - Phone:808-594-6217
Mailing Address - Fax:
Practice Address - Street 1:1110 UNIVERSITY AVE.
Practice Address - Street 2:SUITE #403
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826
Practice Address - Country:US
Practice Address - Phone:808-594-6217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-1502103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical