Provider Demographics
NPI:1306605472
Name:EZAWA, MAIYA STEPHANY MIYOKO
Entity type:Individual
Prefix:
First Name:MAIYA
Middle Name:STEPHANY MIYOKO
Last Name:EZAWA
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 1:95-068 KAULUA ST
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-1510
Mailing Address - Country:US
Mailing Address - Phone:808-673-0595
Mailing Address - Fax:
Practice Address - Street 1:1524 PENSACOLA ST APT 318
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96822-3874
Practice Address - Country:US
Practice Address - Phone:808-312-9307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-24-334706106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician