Healthcare Provider Details

I. General information

NPI: 1023804317
Provider Name (Legal Business Name): BRENDA BAUTISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 04/15/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 SALT LAKE BLVD STE D8
HONOLULU HI
96818-3172
US

IV. Provider business mailing address

44-375 KANEOHE BAY DR
KANEOHE HI
96744-2664
US

V. Phone/Fax

Practice location:
  • Phone: 808-204-2893
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-427938
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: