Provider Demographics
NPI:1356066344
Name:SANDAL GAP COMPREHENSIVE SERVICES
Entity type:Organization
Organization Name:SANDAL GAP COMPREHENSIVE SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-425-0195
Mailing Address - Street 1:126 AIKAHI LOOP
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-1642
Mailing Address - Country:US
Mailing Address - Phone:808-425-0195
Mailing Address - Fax:
Practice Address - Street 1:126 AIKAHI LOOP
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-1642
Practice Address - Country:US
Practice Address - Phone:808-425-0195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-11
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty