Organization
KA IMI PONO, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GAIL LYNN TICE PSY.D. (CLINICAL PSYCHOLOGIST)
(808) 387-5307
Entity
Organization
Contact information
Practice address
1029 KAPAHULU AVE STE 405, HONOLULU, HI 96816-1332
(808) 387-5307
(808) 218-7884
Mailing address
PO BOX 161191, HONOLULU, HI 96816-0925
(808) 387-5307
(808) 218-7884
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
899
HI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1225133481
PERSONAL NPI
HI
Enumeration date
01/28/2008
Last updated
01/28/2008
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