Provider Demographics
NPI:1285462234
Name:ISLAND MIND THERAPY LLC
Entity type:Organization
Organization Name:ISLAND MIND THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LLC MANAGER / MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANNING
Authorized Official - Middle Name:
Authorized Official - Last Name:SLATE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-229-3434
Mailing Address - Street 1:1955 MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1741
Mailing Address - Country:US
Mailing Address - Phone:808-229-3200
Mailing Address - Fax:
Practice Address - Street 1:1955 MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1741
Practice Address - Country:US
Practice Address - Phone:808-987-6404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-22
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty