Provider Demographics
NPI:1497909154
Name:DOMINGO-YAMAMOTO, CHARLENE DICHOSO (LAC, MACOM)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:DICHOSO
Last Name:DOMINGO-YAMAMOTO
Suffix:
Gender:F
Credentials:LAC, MACOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9159 W DESERT INN RD APT J104
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-6372
Mailing Address - Country:US
Mailing Address - Phone:808-554-3257
Mailing Address - Fax:
Practice Address - Street 1:1750 KALAKAUA AVE
Practice Address - Street 2:SUITE 808
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-3766
Practice Address - Country:US
Practice Address - Phone:808-589-6937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT2888106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician