Basic Information
| Provider Information | |||||||||
| NPI: | 1396404877 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEACON OF LASTING CHANGE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5984 GANNET AVE | ||||||||
| Address2: | |||||||||
| City: | EWA BEACH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967063239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086001132 | ||||||||
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| Practice Location | |||||||||
| Address1: | 438 HOBRON LN STE 311 | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968151229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086001132 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2021 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | MARKS | ||||||||
| AuthorizedOfficialFirstName: | MAITA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8086001132 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LMFT | ||||||||
| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.