Provider Demographics
NPI:1245002336
Name:KINTSUGI CENTER FOR HEALING LLC
Entity type:Organization
Organization Name:KINTSUGI CENTER FOR HEALING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:408-614-4854
Mailing Address - Street 1:91-1014 ALEPA ST
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-1901
Mailing Address - Country:US
Mailing Address - Phone:408-614-4854
Mailing Address - Fax:
Practice Address - Street 1:98-211 PALI MOMI ST STE 600
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4337
Practice Address - Country:US
Practice Address - Phone:808-201-9059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty