Basic Information
| Provider Information | |||||||||
| NPI: | 1811530314 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | MISHEA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95-935 UKUWAI ST APT 702 | ||||||||
| Address2: | |||||||||
| City: | MILILANI | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967895929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8087251280 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1330 ALA MOANA BLVD STE 1 | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968144262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085851424 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2019 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MHC-614 | HI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | MHC-614 | 05 | HI | MEDICAID |