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General NPI Number Information
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NPI Number | 1861002479
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Entity Type | Individual
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Provider Name | CARISSA THIBODEAUX RBT
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Gender | Female
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Dates
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Enumeration Date | 08/07/2020
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Last Update Date | 08/07/2020
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Provider Practice Location Address
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Address Line | 500 ALA MOANA BLVD STE 7400
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City | HONOLULU
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State | HI
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Zip | 96813-4902
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Country | US
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Telephone | 808-354-0090
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Fax |
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Provider Business Mailing Address
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Address Line | 2649 VARSITY PL APT 212
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City | HONOLULU
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State | HI
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Zip | 96826-1640
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Country | US
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Telephone | 808-793-8773
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | BACB594819
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License Number State | HI
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