Healthcare Provider Details

I. General information

NPI: 1619602547
Provider Name (Legal Business Name): SANDRA DZATHOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 07/25/2022
Certification Date: 07/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 MILLER ST
HONOLULU HI
96813-2493
US

IV. Provider business mailing address

1390 MILLER ST
HONOLULU HI
96813-2493
US

V. Phone/Fax

Practice location:
  • Phone: 302-722-1208
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: