Provider Demographics
NPI:1578254181
Name:LOPEZ, SEAN JOSHUA MEDRANO (RBT)
Entity Type:Individual
Prefix:
First Name:SEAN JOSHUA
Middle Name:MEDRANO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 SALT LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-3153
Mailing Address - Country:US
Mailing Address - Phone:808-486-1804
Mailing Address - Fax:
Practice Address - Street 1:94-428 MOKUOLA ST STE 214A
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3396
Practice Address - Country:US
Practice Address - Phone:808-944-2882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
HIRBT-23-281526106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician