Provider Demographics
NPI:1114579778
Name:KONVIT, LINDA MARIE (BCABA)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:MARIE
Last Name:KONVIT
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ALA MAKANI ST
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-3533
Mailing Address - Country:US
Mailing Address - Phone:808-877-1502
Mailing Address - Fax:
Practice Address - Street 1:427 ALA MAKANI ST STE 200
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-3507
Practice Address - Country:US
Practice Address - Phone:808-244-6879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-14
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
HI0-21-11807106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI820185Medicaid