Basic Information
| Provider Information | |||||||||
| NPI: | 1720748296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDRY | ||||||||
| FirstName: | FAWN | ||||||||
| MiddleName: | HEATHER | ||||||||
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| Credential: | MSW, CSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 84-529 MANUKU ST | ||||||||
| Address2: | |||||||||
| City: | WAIANAE | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967921853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8087810249 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1330 ALA MOANA BLVD STE 1 | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968144262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085851424 | ||||||||
| FaxNumber: | 8085850379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2021 | ||||||||
| LastUpdateDate: | 12/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.