Provider Demographics
NPI:1427767680
Name:BRAY, FERNANDA IBARRA
Entity type:Individual
Prefix:MRS
First Name:FERNANDA
Middle Name:IBARRA
Last Name:BRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FERNANDA
Other - Middle Name:IBARRA
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:46-1016 EMEPELA WAY APT 22T
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-3908
Mailing Address - Country:US
Mailing Address - Phone:606-275-5225
Mailing Address - Fax:
Practice Address - Street 1:46-1016 EMEPELA WAY APT 22T
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-3908
Practice Address - Country:US
Practice Address - Phone:606-275-5225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI21-187872106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician