Basic Information
Provider Information | |||||||||
NPI: | 1912397803 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ECHIVERRI | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | BSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 161 S WAKEA AVE | ||||||||
Address2: |   | ||||||||
City: | KAHULUI | ||||||||
State: | HI | ||||||||
PostalCode: | 967321343 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8082447467 | ||||||||
FaxNumber: | 8082424762 | ||||||||
Practice Location | |||||||||
Address1: | 161 S WAKEA AVE | ||||||||
Address2: |   | ||||||||
City: | KAHULUI | ||||||||
State: | HI | ||||||||
PostalCode: | 967321343 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8082447467 | ||||||||
FaxNumber: | 8082424762 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2015 | ||||||||
LastUpdateDate: | 11/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
ID Information
ID | Type | State | Issuer | Description | XLFR000081136244 | 01 | HI | HMSA | OTHER |