Provider Demographics
NPI:1811582281
Name:NAGATAKE, MADOKA
Entity Type:Individual
Prefix:
First Name:MADOKA
Middle Name:
Last Name:NAGATAKE
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 1:92-7000 PULIKO ST
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4510 SALT LAKE BLVD STE D8
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96818-3172
Practice Address - Country:US
Practice Address - Phone:808-486-1804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-07
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
RBT-21-161364106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician