Provider Demographics
NPI:1548496417
Name:VANCE, KATHLEEN SACHIKO (LCSW, CSAC)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:SACHIKO
Last Name:VANCE
Suffix:
Gender:F
Credentials:LCSW, CSAC
Other - Prefix:MS
Other - First Name:KATHY
Other - Middle Name:SACHIKO
Other - Last Name:VANCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW, CSAC
Mailing Address - Street 1:442 KANANI PL
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-1737
Mailing Address - Country:US
Mailing Address - Phone:808-224-8551
Mailing Address - Fax:808-595-6451
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:
Practice Address - City:TRIPLER ARMY MEDICAL CENTER
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-7699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1150-02101YA0400X
HI32891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicare UPIN