Provider Demographics
NPI:1588091219
Name:BAIN, ILEA (PSYD)
Entity type:Individual
Prefix:
First Name:ILEA
Middle Name:
Last Name:BAIN
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 1:45-549 PLUMERIA ST
Mailing Address - Street 2:
Mailing Address - City:HONOKAA
Mailing Address - State:HI
Mailing Address - Zip Code:96727-6902
Mailing Address - Country:US
Mailing Address - Phone:808-775-7204
Mailing Address - Fax:808-775-9404
Practice Address - Street 1:53-3925 AKONI PULE HIGHWAY
Practice Address - Street 2:
Practice Address - City:KAPAAU
Practice Address - State:HI
Practice Address - Zip Code:96755
Practice Address - Country:US
Practice Address - Phone:808-889-6236
Practice Address - Fax:808-889-0107
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2763103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical