Basic Information
| Provider Information | |||||||||
| NPI: | 1376947119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEALOHA | ||||||||
| FirstName: | CHANEL | ||||||||
| MiddleName: | EVALANI | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 564 SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968135013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085911173 | ||||||||
| FaxNumber: | 8085911174 | ||||||||
| Practice Location | |||||||||
| Address1: | 3020 CHILDRENS WAY # MC5042 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589667453 | ||||||||
| FaxNumber: | 8589668011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2014 | ||||||||
| LastUpdateDate: | 01/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 31266 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | PSY 1487 | HI | N | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.