Provider Demographics
NPI:1396399754
Name:HAGBLOM, WILLIAM G
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:G
Last Name:HAGBLOM
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 1:828 LAULA WAY
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-2246
Mailing Address - Country:US
Mailing Address - Phone:619-972-7567
Mailing Address - Fax:
Practice Address - Street 1:200 N VINEYARD BLVD # B-120
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-3950
Practice Address - Country:US
Practice Address - Phone:808-536-1015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician