Provider Demographics
NPI:1083453898
Name:BRADY, TAYLOR LATRECE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:LATRECE
Last Name:BRADY
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 1:369 N VINEYARD BLVD # 7204
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-3638
Mailing Address - Country:US
Mailing Address - Phone:808-698-9559
Mailing Address - Fax:
Practice Address - Street 1:1917 COLBURN ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-3248
Practice Address - Country:US
Practice Address - Phone:808-393-9826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician