Provider Demographics
NPI:1740742113
Name:LE, RANDY DOAN (RBT)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:DOAN
Last Name:LE
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 1:126 NEFF ST # 669
Mailing Address - Street 2:
Mailing Address - City:WAHIAWA
Mailing Address - State:HI
Mailing Address - Zip Code:96786-3626
Mailing Address - Country:US
Mailing Address - Phone:956-376-6435
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
Practice Address - Country:US
Practice Address - Phone:956-376-6435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1980239106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty