Provider Demographics
NPI:1710463773
Name:BROSTROM, NAOMI
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:
Last Name:BROSTROM
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 1:1122 KRUKOWSKI RD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-1558
Mailing Address - Country:US
Mailing Address - Phone:808-388-2113
Mailing Address - Fax:
Practice Address - Street 1:4510 SALT LAKE BLVD STE B6
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96818-3171
Practice Address - Country:US
Practice Address - Phone:808-597-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician