Provider Demographics
NPI:1073105565
Name:FORMENT, RACHEL
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:FORMENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LUNA
Other - Middle Name:
Other - Last Name:FORMENT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:400 HUALANI ST APT 374
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-6413
Mailing Address - Country:US
Mailing Address - Phone:305-586-6232
Mailing Address - Fax:
Practice Address - Street 1:400 HUALANI ST APT 374
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-6413
Practice Address - Country:US
Practice Address - Phone:305-586-6232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-07
Last Update Date:2021-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-21-154837106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician