Provider Demographics
NPI:1942870712
Name:HOLDERBAUM, BRYNN ALYSE
Entity Type:Individual
Prefix:
First Name:BRYNN
Middle Name:ALYSE
Last Name:HOLDERBAUM
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 1:3044 LAKIMAU ST APT A
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-4200
Mailing Address - Country:US
Mailing Address - Phone:623-203-6407
Mailing Address - Fax:
Practice Address - Street 1:1390 MILLER ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2493
Practice Address - Country:US
Practice Address - Phone:808-586-3230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD09380886106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician