Provider Demographics
NPI:1659987782
Name:AYRES, KASSIDY
Entity Type:Individual
Prefix:
First Name:KASSIDY
Middle Name:
Last Name:AYRES
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 1:92-1510 ALIINUI DR # VILLA7
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-4405
Mailing Address - Country:US
Mailing Address - Phone:845-608-3277
Mailing Address - Fax:
Practice Address - Street 1:94-428 MOKUOLA ST
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-6300
Practice Address - Country:US
Practice Address - Phone:808-944-2882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
RBT-20-136505106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician