Provider Demographics
NPI:1235755067
Name:GOMES, COURTNEY KEALAILANI
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:KEALAILANI
Last Name:GOMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-3631
Mailing Address - Country:US
Mailing Address - Phone:808-268-4841
Mailing Address - Fax:
Practice Address - Street 1:94-450 MOKUOLA ST STE 100
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3388
Practice Address - Country:US
Practice Address - Phone:415-989-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
HI20-124379106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician