MEDICARE: DONNA MARIA KIM

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	106S00000X	Behavior Technician	15-10827	HI

General Provider Information

NPI Number	:	1821636762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA MARIA KIM

Provider Business Mailing Address
First Line	:	4510 SALT LAKE BLVD STE B6
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96818-3171
Country	:	US
Telephone Number	:	808-486-1804
Fax Number	:

Provider Business Practice Location Address
First Line	:	4510 SALT LAKE BLVD STE B6
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96818-3171
Country	:	US
Telephone Number	:	808-486-1804
Fax Number	:

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

Provider Enumeration Date	:	12/10/2019
Last Update Date	:	12/10/2019

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