Provider Demographics
NPI:1346763836
Name:AUTISM SERVICES KAUAI LLC
Entity Type:Organization
Organization Name:AUTISM SERVICES KAUAI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GAMBY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:808-821-2027
Mailing Address - Street 1:4-1558 KUHIO HWY
Mailing Address - Street 2:
Mailing Address - City:KAPAA
Mailing Address - State:HI
Mailing Address - Zip Code:96746-1856
Mailing Address - Country:US
Mailing Address - Phone:1808-821-2027
Mailing Address - Fax:808-821-2028
Practice Address - Street 1:4-1558 KUHIO HWY
Practice Address - Street 2:
Practice Address - City:KAPAA
Practice Address - State:HI
Practice Address - Zip Code:96746-1856
Practice Address - Country:US
Practice Address - Phone:1808-821-2027
Practice Address - Fax:808-821-2028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIBA-93103K00000X
HIPSY-873103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI55958601Medicaid