Provider Demographics
NPI:1386869691
Name:SAMALA, GINA ANN LEONG (PSYD)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:ANN LEONG
Last Name:SAMALA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:WAIALUA
Mailing Address - State:HI
Mailing Address - Zip Code:96791-0125
Mailing Address - Country:US
Mailing Address - Phone:808-625-7448
Mailing Address - Fax:808-200-1186
Practice Address - Street 1:95-1249 MEHEULA PKWY
Practice Address - Street 2:STE 195
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-1791
Practice Address - Country:US
Practice Address - Phone:808-625-7448
Practice Address - Fax:808-625-7448
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-756103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI912194012Medicaid
HIH56629Medicare ID - Type UnspecifiedMEDICARE PROVIDER #