Provider Demographics
NPI:1649354853
Name:MAAKESTAD SULLIVAN, LAURA CORINNE (M A, LMHC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:CORINNE
Last Name:MAAKESTAD SULLIVAN
Suffix:
Gender:F
Credentials:M A, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84-680 KILI DR
Mailing Address - Street 2:SUITE #803
Mailing Address - City:WAIANAE
Mailing Address - State:HI
Mailing Address - Zip Code:96792-1524
Mailing Address - Country:US
Mailing Address - Phone:808-888-9237
Mailing Address - Fax:
Practice Address - Street 1:84-680 KILI DR
Practice Address - Street 2:SUITE #803
Practice Address - City:WAIANAE
Practice Address - State:HI
Practice Address - Zip Code:96792-1524
Practice Address - Country:US
Practice Address - Phone:808-888-9237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI36101YM0800X
WALH00006237101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI105HI03587OtherHMSA