Provider Demographics
NPI:1962076422
Name:INNERST, MYKAYLA JEAN (BEHAVIOR TECHNICIAN)
Entity type:Individual
Prefix:
First Name:MYKAYLA
Middle Name:JEAN
Last Name:INNERST
Suffix:
Gender:F
Credentials:BEHAVIOR TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1001 KEAUNUI DR UNIT 362
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-6345
Mailing Address - Country:US
Mailing Address - Phone:602-403-4317
Mailing Address - Fax:
Practice Address - Street 1:1330 ALA MOANA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4262
Practice Address - Country:US
Practice Address - Phone:808-585-1424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty