MEDICARE: MRS. WILLY GRACE P BUNGHANOY-DIAMA BCBA, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-12-11848	HI
2	1041C0700X	Clinical Social Worker	4821	HI

General Provider Information

NPI Number	:	1063852705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. WILLY GRACE P BUNGHANOY-DIAMA BCBA, LCSW

Provider Business Mailing Address
First Line	:	4510 SALT LAKE BLVD
Second Line	:	SUITE D-8
City	:	HONOLULU
State	:	HI
Zip	:	96818-3153
Country	:	US
Telephone Number	:	808-591-6060
Fax Number	:	808-591-6233

Provider Business Practice Location Address
First Line	:	4510 SALT LAKE BLVD
Second Line	:	SUITE D-8
City	:	HONOLULU
State	:	HI
Zip	:	96818-3153
Country	:	US
Telephone Number	:	808-591-6060
Fax Number	:	808-591-6233

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2013
Last Update Date	:	05/23/2022

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