Provider Demographics
NPI:1548738735
Name:BOURRET, SOPHIE M (BCBA)
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:M
Last Name:BOURRET
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 KALANIANAOLE HWY SPC 5001
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-4669
Mailing Address - Country:US
Mailing Address - Phone:808-247-2973
Mailing Address - Fax:
Practice Address - Street 1:203 KAPAA QUARRY PL
Practice Address - Street 2:#5002
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734
Practice Address - Country:US
Practice Address - Phone:808-247-2973
Practice Address - Fax:808-427-3472
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
HI0-22-13497106E00000X
HIBA-758103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHNJC2012121OtherCONTINENTAL CARE