=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740742113
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDY DOAN LE RBT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2019
-----------------------------------------------------
Last Update Date | 04/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4510 SALT LAKE BLVD
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-376-6435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126 NEFF ST # 669
-----------------------------------------------------
City | WAHIAWA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96786-3626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-376-6435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | 1980239
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------