Provider Demographics
NPI:1154837144
Name:BAMBA, JON (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:BAMBA
Suffix:
Gender:M
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67-1185 MAMALAHOA HWY D104 PMB115
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743
Mailing Address - Country:US
Mailing Address - Phone:808-300-9059
Mailing Address - Fax:
Practice Address - Street 1:65-1692 KOHALA MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8476
Practice Address - Country:US
Practice Address - Phone:808-300-9059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-28
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIBA-725103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI93-2028125Medicaid