Provider Demographics
NPI:1689150542
Name:GRAHAM, GAVIN KALUA
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:KALUA
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99-1410 HALAWA HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-3115
Mailing Address - Country:US
Mailing Address - Phone:808-681-2697
Mailing Address - Fax:
Practice Address - Street 1:4510 SALT LAKE BLVD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96818-3153
Practice Address - Country:US
Practice Address - Phone:808-591-6068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-18-53663106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician