Provider Demographics
NPI:1285164327
Name:TAYLOR, JOHANNA (BCBA)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 HEKAU ST
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-4222
Mailing Address - Country:US
Mailing Address - Phone:425-870-3111
Mailing Address - Fax:
Practice Address - Street 1:1131 HEKAU ST
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4222
Practice Address - Country:US
Practice Address - Phone:425-870-9311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-17-34576106S00000X
106S00000X
HI344103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI004871Medicaid