Provider Demographics
NPI:1649464355
Name:BEARDEN PSYCHOLOGICAL SERVICES LLC
Entity type:Organization
Organization Name:BEARDEN PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:STENNIS
Authorized Official - Last Name:BEARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:808-935-2605
Mailing Address - Street 1:101 AUPUNI ST
Mailing Address - Street 2:SUITE 1014 A-2
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-4246
Mailing Address - Country:US
Mailing Address - Phone:808-935-2605
Mailing Address - Fax:808-935-2650
Practice Address - Street 1:101 AUPUNI ST
Practice Address - Street 2:SUITE 1014 A-2
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4246
Practice Address - Country:US
Practice Address - Phone:808-935-2605
Practice Address - Fax:808-935-2650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY 888261QM0855X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIEL051AMedicare PIN