Provider Demographics
NPI:1053896266
Name:MAGELLAN THERAPEUTIC SERVICES, LLC
Entity type:Organization
Organization Name:MAGELLAN THERAPEUTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDEE
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLEZA
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:808-223-2331
Mailing Address - Street 1:94-1189 NANILIHILIHI ST
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-4134
Mailing Address - Country:US
Mailing Address - Phone:808-223-2331
Mailing Address - Fax:808-356-1546
Practice Address - Street 1:94-1388 MOANIANI ST STE 214
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-6604
Practice Address - Country:US
Practice Address - Phone:808-223-2331
Practice Address - Fax:808-356-1546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health