Provider Demographics
NPI:1588315949
Name:KOSHIMIZU, KEALA KEIKO (LCSW)
Entity type:Individual
Prefix:
First Name:KEALA
Middle Name:KEIKO
Last Name:KOSHIMIZU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIT 5071
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96328-5071
Mailing Address - Country:US
Mailing Address - Phone:315-634-6754
Mailing Address - Fax:
Practice Address - Street 1:UNIT 5071
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96328-5071
Practice Address - Country:US
Practice Address - Phone:315-634-6754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-17
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI46811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical