Provider Information for 1396404877
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BEACON OF LASTING CHANGE, LLC
Organization Subpart: NO
NPI: 1396404877
Last Updated: 2021-12-13
Certification Date: 2021-12-13
Certification Date: 2021-12-13
Details
| Name | Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| NPI | 1396404877 | ||||||||
| Enumeration Date | 2021-12-13 | ||||||||
| NPI Type | NPI-2 Organization | ||||||||
| Status | Active | ||||||||
| Authorized Official Information | Name: Mrs. MAITA MARKS LMFT Title: Manager Phone: 8086001132 | ||||||||
| Mailing Address | 5984 GANNET AVE EWA BEACH, HI 96706-3239 United States Phone: 808-600-1132 | Fax: | ||||||||
| Primary Practice Address | 438 HOBRON LN STE 311 HONOLULU, HI 96815-1229 United States Phone: 808-600-1132 | Fax: | ||||||||
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