Provider Demographics
NPI:1285040543
Name:FAY, JOSHUA
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:FAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 3 BOX 11017
Mailing Address - Street 2:
Mailing Address - City:KEAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96749-9205
Mailing Address - Country:US
Mailing Address - Phone:786-777-8584
Mailing Address - Fax:305-597-3863
Practice Address - Street 1:1255 KILAUEA AVE STE 200
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4205
Practice Address - Country:US
Practice Address - Phone:305-597-3861
Practice Address - Fax:305-597-3863
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
HI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program