Provider Demographics
NPI:1538832696
Name:GRACE, ZACHERY
Entity type:Individual
Prefix:
First Name:ZACHERY
Middle Name:
Last Name:GRACE
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 1:1475 LINAPUNI ST APT 1116
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-3551
Mailing Address - Country:US
Mailing Address - Phone:808-763-7887
Mailing Address - Fax:
Practice Address - Street 1:91-5007 KAPOLEI PKWY
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-3201
Practice Address - Country:US
Practice Address - Phone:808-305-8320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-20-135010106S00000X
HILBA-880-0103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician