Provider Demographics
NPI:1447849609
Name:WILSON-LANDRUM, TIFFANY JA'RAE (MA, PSYD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:JA'RAE
Last Name:WILSON-LANDRUM
Suffix:
Gender:F
Credentials:MA, PSYD
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:JA'RAE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:86-058 ALTA ST
Mailing Address - Street 2:
Mailing Address - City:WAIANAE
Mailing Address - State:HI
Mailing Address - Zip Code:96792-3031
Mailing Address - Country:US
Mailing Address - Phone:808-358-0800
Mailing Address - Fax:808-525-6256
Practice Address - Street 1:1441 KAPIOLANI BLVD STE 1802
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4408
Practice Address - Country:US
Practice Address - Phone:808-525-6255
Practice Address - Fax:808-525-6256
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2023-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-1909103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical