Provider Demographics
NPI:1336806157
Name:BIRD, KELLIE (MED)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:BIRD
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:SHANAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:101A SIGNER BLVD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-4924
Mailing Address - Country:US
Mailing Address - Phone:410-960-5111
Mailing Address - Fax:
Practice Address - Street 1:1330 ALA MOANA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4262
Practice Address - Country:US
Practice Address - Phone:808-585-1424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician