Provider Demographics
NPI:1245912831
Name:POEPOE AYALA, MANDY MCKAE
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:MCKAE
Last Name:POEPOE AYALA
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 1:100 KAHELU AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-3913
Mailing Address - Country:US
Mailing Address - Phone:808-625-3000
Mailing Address - Fax:
Practice Address - Street 1:3922 WISEMAN BLVD BLDG 4
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-1668
Practice Address - Country:US
Practice Address - Phone:210-981-6836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician