Basic Information
| Provider Information | |||||||||
| NPI: | 1881790590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREEDLE | ||||||||
| FirstName: | LORRAINE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D, LISW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4249 | ||||||||
| Address2: | |||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967200249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083451726 | ||||||||
| FaxNumber: | 8083157204 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 KAHOA ST | ||||||||
| Address2: | |||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967202205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083451726 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 04/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PA-0938 | NM | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103G00000X | PSY-1150 | HI | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 1041C0700X | I-2145 | NM | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LCSW-3980 | HI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 103TC0700X | 1037 | NM | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.