Provider Demographics
NPI:1770198921
Name:ERTEL, BESSIE MAE BETHANY STAR
Entity Type:Individual
Prefix:MRS
First Name:BESSIE
Middle Name:MAE BETHANY STAR
Last Name:ERTEL
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:BESSIE
Other - Middle Name:MAE BETHANY STAR
Other - Last Name:DOWNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3002 GLEN COVE LN
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-4771
Mailing Address - Country:US
Mailing Address - Phone:904-909-1600
Mailing Address - Fax:
Practice Address - Street 1:615 PIIKOI ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-3116
Practice Address - Country:US
Practice Address - Phone:808-591-6068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician