Provider Demographics
NPI:1740503929
Name:MERRITT, CHARLENE S (CSCAC, ICADC)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:S
Last Name:MERRITT
Suffix:
Gender:F
Credentials:CSCAC, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 WAIANUENUE AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2474
Mailing Address - Country:US
Mailing Address - Phone:808-935-4412
Mailing Address - Fax:
Practice Address - Street 1:56 WAIANUENUE AVE STE 202
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2474
Practice Address - Country:US
Practice Address - Phone:808-935-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1318-07101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)