Basic Information
| Provider Information | |||||||||
| NPI: | 1114690492 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMRAM | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | TIANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 98-135 LIPOA PL APT 101 | ||||||||
| Address2: | |||||||||
| City: | AIEA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967014893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083645018 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1001 KAMOKILA BLVD STE 210 | ||||||||
| Address2: | |||||||||
| City: | KAPOLEI | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967072096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085916060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2021 | ||||||||
| LastUpdateDate: | 07/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106E00000X | N | 247200000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 106S00000X | Y |
No ID Information.