Provider Demographics
NPI:1528604477
Name:CLARK, DAYSHA
Entity Type:Individual
Prefix:
First Name:DAYSHA
Middle Name:
Last Name:CLARK
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 1:87-107 KAHAU ST
Mailing Address - Street 2:
Mailing Address - City:WAIANAE
Mailing Address - State:HI
Mailing Address - Zip Code:96792-3650
Mailing Address - Country:US
Mailing Address - Phone:808-778-8421
Mailing Address - Fax:
Practice Address - Street 1:94-1221 KA UKA BLVD
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-6202
Practice Address - Country:US
Practice Address - Phone:808-773-2792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-19-106975106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician