Basic Information
Provider Information | |||||||||
NPI: | 1225530058 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GERNENZ | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | LMHC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1330 ALA MOANA BLVD | ||||||||
Address2: |   | ||||||||
City: | HONOLULU | ||||||||
State: | HI | ||||||||
PostalCode: | 968144200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8085851424 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 66-665 HALEIWA RD | ||||||||
Address2: |   | ||||||||
City: | HALEIWA | ||||||||
State: | HI | ||||||||
PostalCode: | 967121528 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8087987839 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2018 | ||||||||
LastUpdateDate: | 09/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X |   |   | N |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   | 101YM0800X | MHC-801 | HI | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.