Provider Demographics
NPI:1679523153
Name:GINO, ANTONIO (PHD, CSAC)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:
Last Name:GINO
Suffix:
Gender:M
Credentials:PHD, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25972
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-0972
Mailing Address - Country:US
Mailing Address - Phone:808-528-1184
Mailing Address - Fax:
Practice Address - Street 1:1154 FORT STREET MALL STE 206
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2712
Practice Address - Country:US
Practice Address - Phone:808-528-1184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-475103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00137401Medicaid
HI00137401Medicaid