Healthcare Provider Details

I. General information

NPI: 1255840393
Provider Name (Legal Business Name): MELODY ERICSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELODY MANSOUR

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 07/21/2022
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 KAPAA QUARRY PL #5002
KAILUA HI
96734
US

IV. Provider business mailing address

99-870 IWAENA ST # 101
AIEA HI
96701-3278
US

V. Phone/Fax

Practice location:
  • Phone: 808-247-2973
  • Fax:
Mailing address:
  • Phone: 808-277-7736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBA-430
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: