Provider Demographics
NPI:1831814284
Name:MELISSA WILSON LMFT LLC
Entity type:Organization
Organization Name:MELISSA WILSON LMFT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:808-651-4183
Mailing Address - Street 1:3877D OMAO RD
Mailing Address - Street 2:
Mailing Address - City:KOLOA
Mailing Address - State:HI
Mailing Address - Zip Code:96756-9615
Mailing Address - Country:US
Mailing Address - Phone:808-651-4183
Mailing Address - Fax:
Practice Address - Street 1:4374 KUKUI GROVE ST STE 102
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-2007
Practice Address - Country:US
Practice Address - Phone:808-651-4183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-07
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1285900084Medicaid