Provider Demographics
NPI:1306271093
Name:LO, GRACIETE (PHD)
Entity type:Individual
Prefix:MS
First Name:GRACIETE
Middle Name:
Last Name:LO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3215 ALA ILIMA ST APT B501
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-2908
Mailing Address - Country:US
Mailing Address - Phone:646-284-4551
Mailing Address - Fax:
Practice Address - Street 1:2855 E MANOA RD STE 105
Practice Address - Street 2:#159
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96822
Practice Address - Country:US
Practice Address - Phone:646-801-8219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020268103T00000X
HIPSY-1433103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist