Provider Demographics
NPI:1851890008
Name:SMITH, KEENAN DOUGLAS (RBT)
Entity Type:Individual
Prefix:
First Name:KEENAN
Middle Name:DOUGLAS
Last Name:SMITH
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 1:455 HUALANI ST
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-5534
Mailing Address - Country:US
Mailing Address - Phone:808-344-0526
Mailing Address - Fax:
Practice Address - Street 1:94-1221 KA UKA BLVD STE 108
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-6299
Practice Address - Country:US
Practice Address - Phone:808-292-7968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI16-18268106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician