Provider Demographics
NPI:1487879789
Name:KAUAI COMMUNITY MENTAL HEALTH CENTER
Entity type:Organization
Organization Name:KAUAI COMMUNITY MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CENTER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DETUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:808-274-3190
Mailing Address - Street 1:3-3212 KUHIO HWY
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-1142
Mailing Address - Country:US
Mailing Address - Phone:808-274-3190
Mailing Address - Fax:808-274-3194
Practice Address - Street 1:3-3212 KUHIO HWY
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-1142
Practice Address - Country:US
Practice Address - Phone:808-274-3190
Practice Address - Fax:808-274-3194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI539372-01Medicaid
HI539372-01Medicaid