Provider Demographics
NPI:1215299979
Name:NORTH HAWAII CHILD DEVELOPMENT PROGRAM
Entity type:Organization
Organization Name:NORTH HAWAII CHILD DEVELOPMENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:DE COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MFT, CSAC
Authorized Official - Phone:808-885-0086
Mailing Address - Street 1:64-1032 MAMALAHOA HWY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-8441
Mailing Address - Country:US
Mailing Address - Phone:808-885-0086
Mailing Address - Fax:808-885-8054
Practice Address - Street 1:64-1032 MAMALAHOA HWY
Practice Address - Street 2:SUITE 204
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8441
Practice Address - Country:US
Practice Address - Phone:808-885-0086
Practice Address - Fax:808-885-8054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI64642403Medicaid