Provider Demographics
NPI:1194282152
Name:TELLEZ, MICHELLE ALYSSA (RBT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ALYSSA
Last Name:TELLEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 LIME ST APT 404
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96826-4177
Mailing Address - Country:US
Mailing Address - Phone:760-556-7513
Mailing Address - Fax:
Practice Address - Street 1:2122 LIME ST APT 404
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-4177
Practice Address - Country:US
Practice Address - Phone:760-556-7513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-19-79102106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician