Provider Demographics
NPI:1679299507
Name:MANDALA INTEGRATIVE THERAPY, LLC
Entity type:Organization
Organization Name:MANDALA INTEGRATIVE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:VAN DER TUIN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:808-276-4160
Mailing Address - Street 1:4198 KILAUEA AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-4452
Mailing Address - Country:US
Mailing Address - Phone:808-276-4160
Mailing Address - Fax:
Practice Address - Street 1:4198 KILAUEA AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-4452
Practice Address - Country:US
Practice Address - Phone:808-276-4160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty