Provider Demographics
NPI:1275200230
Name:BALMOJA, CASSANDRA
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:BALMOJA
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 1:55 WAIAKA LN APT 201
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2000
Mailing Address - Country:US
Mailing Address - Phone:808-365-8808
Mailing Address - Fax:
Practice Address - Street 1:553 WAINEE ST
Practice Address - Street 2:
Practice Address - City:LAHAINA
Practice Address - State:HI
Practice Address - Zip Code:96761-1109
Practice Address - Country:US
Practice Address - Phone:808-446-4561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-21-182041106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty