Provider Demographics
NPI:1952070807
Name:BOSE, JUSTIN DELMAR (RBT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DELMAR
Last Name:BOSE
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 1:6358 IBIS AVE
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3332
Mailing Address - Country:US
Mailing Address - Phone:206-498-8564
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:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician