Provider Demographics
NPI:1225601594
Name:WILSON, KEVIN LEMAR
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEMAR
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 KAMOKILA BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2096
Mailing Address - Country:US
Mailing Address - Phone:808-591-6060
Mailing Address - Fax:
Practice Address - Street 1:4680 KALANIANAOLE HWY
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96821-1241
Practice Address - Country:US
Practice Address - Phone:808-305-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-21-160003106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician