Provider Demographics
NPI:1326693961
Name:SMITH, KENDRICK NOEL
Entity Type:Individual
Prefix:
First Name:KENDRICK
Middle Name:NOEL
Last Name:SMITH
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 1:94-450 MOKUOLA STREET
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-1270
Mailing Address - Country:US
Mailing Address - Phone:808-944-2882
Mailing Address - Fax:
Practice Address - Street 1:94-450 MOKUOLA ST
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:808-944-2882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI517569106S00000X
106S00000X
HIRBT-19-95448106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician