Healthcare Provider Details

I. General information

NPI: 1083135883
Provider Name (Legal Business Name): AMANDA JEAN HAACK BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 SOUTH ST
HONOLULU HI
96813-5013
US

IV. Provider business mailing address

564 SOUTH ST
HONOLULU HI
96813-5013
US

V. Phone/Fax

Practice location:
  • Phone: 808-591-1173
  • Fax: 808-591-1174
Mailing address:
  • Phone: 808-591-1173
  • Fax: 808-591-1174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-36200
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: