Provider Demographics
NPI:1629592399
Name:KANAHELE, LACEY RAE
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:RAE
Last Name:KANAHELE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:RAE
Other - Last Name:HENDRICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1222
Mailing Address - Street 2:
Mailing Address - City:KEKAHA
Mailing Address - State:HI
Mailing Address - Zip Code:96752-1222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4560 AKIKIKI PL.
Practice Address - Street 2:
Practice Address - City:KEKAHA
Practice Address - State:HI
Practice Address - Zip Code:96752
Practice Address - Country:US
Practice Address - Phone:808-635-0185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician