Provider Demographics
NPI:1992240980
Name:FERNANDES, VICTOR
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:FERNANDES
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:PO BOX 385021
Mailing Address - Street 2:
Mailing Address - City:WAIKOLOA
Mailing Address - State:HI
Mailing Address - Zip Code:96738-5021
Mailing Address - Country:US
Mailing Address - Phone:561-386-9800
Mailing Address - Fax:
Practice Address - Street 1:65-1279 KAWAIHAE RD SUITE 208
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743
Practice Address - Country:US
Practice Address - Phone:808-491-9661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-16-12894106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician