Basic Information
| Provider Information | |||||||||
| NPI: | 1063852705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUNGHANOY-DIAMA | ||||||||
| FirstName: | WILLY GRACE | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4510 SALT LAKE BLVD | ||||||||
| Address2: | SUITE D-8 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968183153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085916060 | ||||||||
| FaxNumber: | 8085916233 | ||||||||
| Practice Location | |||||||||
| Address1: | 4510 SALT LAKE BLVD | ||||||||
| Address2: | SUITE D-8 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968183153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085916060 | ||||||||
| FaxNumber: | 8085916233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2013 | ||||||||
| LastUpdateDate: | 05/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-12-11848 | HI | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 1041C0700X | 4821 | HI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.