Provider Demographics
NPI:1194964353
Name:PSYCHOLOGICAL SERVICE CENTER, LLC
Entity type:Organization
Organization Name:PSYCHOLOGICAL SERVICE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:808-280-9457
Mailing Address - Street 1:126 PENI PL
Mailing Address - Street 2:
Mailing Address - City:KULA
Mailing Address - State:HI
Mailing Address - Zip Code:96790-8772
Mailing Address - Country:US
Mailing Address - Phone:808-280-9457
Mailing Address - Fax:808-572-0311
Practice Address - Street 1:1135 MAKAWAO AVE
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-7403
Practice Address - Country:US
Practice Address - Phone:808-280-9457
Practice Address - Fax:808-572-0311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00A0258473OtherHMSA
HI57950002Medicaid
HI548195324OtherUNIVERSITY HEALTH ALLIANCE
HI57950000-1OtherALOHA CARE QUEST
HI548195324OtherUNIVERSITY HEALTH ALLIANCE
HI101482Medicare PIN