Healthcare Provider Details

I. General information

NPI: 1063028264
Provider Name (Legal Business Name): MADDISEN DOMINGO BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N VINEYARD BLVD
HONOLULU HI
96817-3950
US

IV. Provider business mailing address

2730 SHADELANDS DR BLDG 10
WALNUT CREEK CA
94598-2538
US

V. Phone/Fax

Practice location:
  • Phone: 808-536-1015
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number423
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: